CIHM 
Microfiche 
Series 
({Monographs) 


ICIMH 

Collection  de 
microfiches 
(monographies) 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  canadien  de  microreproductions  historiques 


Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  for  filming.  Features  of  this  copy  which 
may  be  bibliographically  un  que,  which  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 


□   Coloured  covers  / 
Couverture  de  couleur 


□ 

D 

D 
D 

□ 


□ 
□ 
□ 


D 


Covers  damaged  / 
Couverture  endommagee 

Covers  restored  and/or  laminated  / 
Couverture  restaur6e  et/ou  pelliculte 

Cover  title  missing  /  Le  titre  de  couverture  manque 

Coloured  maps  /  Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations  / 
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1  ight  binding  may  cause  shadows  or  distortion  along 
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interieure. 

Blank  leaves  added  during  restorations  may  appear 
within  the  text.  Whenever  possible,  these  have  been 
omitted  from  filming  /  Use  peut  que  certaines  pages 
blanches  ajoutees  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  lorsque  cela  6tait 
possible,  ces  pages  n'ont  pas  et6  filmees. 


L'Institut  a  microfilm^  le  meilleur  exemplaire  qu'il  lui  a 
6t6  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sent  peut-§tre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modification  dans  la  m^tho- 
de  ncrmale  de  filmage  sont  indiqu^s  ci-dessous. 

I      [   Coloured  pages  /  Pages  de  couleur 

I I   Pages  damaged  /  Pages  endommag6es 


D 


Pages  restcred  and/or  laminated  / 
Pages  restaur^es  et/ou  pellicul^es 


Q  Pages  discoloured,  stained  or  foxed  / 
Pages  d^colordes,  tachet^es  ou  piqu^es 

Pages  detached  /  Pages  d6tach6es 

/     Showthrough  /  Transparence 

I      I   Quality  of  print  varies  / 


D 
D 


D 


Quality  in^gale  de  I'impression 

Includes  supplementary  material  / 
Comprend  du  materiel  suppl^mentaire 

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tissues,  etc.,  have  been  refilmed  to  ensure  the  besi 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  ^te  filmees  a  nouveau  de  fagon  a 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  varying  colouration  or 
aiscolourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
filmees  deux  fois  afin  d'obtenir  la  meilleure  image 
possible. 


7 


Additional  comments  / 
Commentaires  supplementaires: 


Pagination  is  as  follows:      [ij-x,   [17J-759  p. 


This  item  is  filmed  at  the  reduction  ratio  checked  below  / 

Ce  document  est  fiime  au  taux  de  reduction  indique  ci-dessous. 


10x 

14x 

18x 

22x 

26x 

30x 

•" 

12x 


16x 


20x 


24x 


28x 


32x 


The  copy  filmed  h«r«  has  b*«n  reproduced  thanks 
to  the  generosity  of: 

NcCni  University 
Health  Sciences  Library 
Montreal 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifictitions. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  hack  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — ^  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


L'axemplaire  filmA  fut  reproduit  grdce  i  la 
Qtniros'ixi  de: 

McCill   University 
Health  Sciences  Library 
Montreal 

Les  images  suivantes  ont  «t6  reproduites  avec  ie 
plus  grand  soin.  compte  tenu  de  la  condition  et 
de  la  nettet*  de  I'exemplaira  film*,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimis  sent  filmis  en  commenpant 
par  Ie  premier  plat  et  en  terminant  soit  par  la 
derniire  page  qui  comports  une  empreinte 
d'impression  ou  d'illustration,  soit  par  Ie  second 
plat,  selon  Ie  cas.  Tous  les  autres  exemplaires 
origiriaux  sont  filmis  en  commenipant  par  la 
premiere  pege  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  derniire  page  qui  comporte  une  telle 
empreinte. 

Un  des  symboles  suivants  apparaitra  sur  la 
derniAre  image  de  cheque  microfiche,  selon  Ie 
cas:  Ie  symbols  — ••  signifie  "A  SUIVRE ".  Ie 
symbole  V  signifie  "FIN". 

Les  cartes,  planches,  tableaux,  etc.,  peuvent  etre 
film*s  i  des  taux  de  reduction  diffirents. 
Lorsque  Ie  document  est  trop  grand  pour  etre 
reproduit  en  un  seul  cliche,  il  est  film*  i  partir 
de  I'angle  supirieur  gauche,  de  gauche  A  droite, 
et  de  haut  en  bas,  en  prenant  Ie  nombre 
d'imeges  nicessaire.  Les  diagrammes  suiva.-its 
illustrent  la  mdthode. 


1  2  3 


1 

2 

3 

4 

5 

6 

MICROCOPY   RISOIUTION  TEST  CHART 

(ANSI  ond  ISO  TEST  CHART  No,  2) 


[flB  IIIIIM 

■^   la.     12.2 


34 

40 


^  APPLIED  IIVMGE     I 

^^  '6bi    fii!    Ma'f    SUer-'. 

STJS  ftocheslc,    New    ^o'V         14609        ■  SA 

■^S  (716)    482  -  0300  -  Phone 

^S  (^^6)   288  -  5989  -  fa» 


A    TEXT-BOOK 


OF 


PATHOLOGY 

FOR  STUDENTS  OF  JIEDICINE 


BY 
•'.  (iEORfJE  ADAMI,  M.A..  M.I)    KRS 

KELI-OW    OF    JE»l-8    COLLErr      ,.„„  MONTHEAL,    CANADA;    LATE 

LOLLEGE,    (AMBIIIOGE.     ENGLAND 

AND 

lOHN  McCRAE.  M.D.,  M.R.(;. R  (Lovd  ) 

v^..«oN.  LA.E  FELL..W  .N  '>'^'.:>>^^:::::::z:Tzz::z::z:, '-::::-  - 


ILLUSTRATED    W.TH    304    ENGRAVINGS   AND    11    COLORED    PUATE8 


LEA    &    FErnCER 

PHILADELPHIA    AND    NEW    YORK 
1912 

McGiLL  UNIVERSITY, 
MOMTREAL,  Canada 


Ijilcrrd  urcoiiliiiK  tu  the  Ai'l  of  Coiiun->s,  in  the  year  liU'J,  Ity 

\.K.\  .v-  Fi:m(!i;K, 

ill  !lii'  Otiicc  <il'  till    I.ihrariMii  <if  Coiinii'ss.     All  rights  rcMTveii. 


TO 


Till';  MKMOHY 


or 


WVATT  JOIIXSTOX 


PREFAl E 


It  will  at  first  irlaiur  hv  tiioii^lit  that  two  larj;<-  iMiMications  upon 
tlu"  sixmv  snhjfct  by  tlu-  saim-  author  within  a  rrlatiwjy  brief  s|)a('«'  of 
tinu  must  tw  alike  We  venture  to  think  that  the  reader  will  not  find 
in  this  work  any  lengthy  exeerpt  from  "The  I'rineijiles  of  I'atholojiy," 
hut  on  the  eontrary  will  find  considerable  evidence  of  ni(Klification. 
Its  birth,  however,  in  a  certain  si-nst-  may  be  laid  at  the  ijoor  of  the 
previous  work,  to  l)e  presently  explained. 

Lon^  a>;o  on*-  of  the  authors  of  this  work  was  ai)proache<l  by  its 
publishers,  and  lie  agreed  to  write  a  text-book  of  patholo^fy  of  some 
seven  hundred  pajres,  a  book,  in  fact,  the  size  of  this  lyiuK  open  before 
the  reader.  The  result  of  many  years  of  writinj;  and  re-writing  was  a 
mass  of  material  sufficient  to  make  two  volumes  each  of  one  thousand 
pages  or  thereabouts,  one  upon  General  Pathology,  the  other  in  col- 
laboration w  ith  our  colleague  Professor  A.  (I.  Nicholls  upon  Sy.stemic 
and  .Special  Pathology.  The  scheme  and  sco|)e  of  the  mannscrij)t  w«'re 
not  wiuit  the  j)«blishers  had  sought;  ne\ertheless  with  rare  goinl-will 
Messrs.  lica  &  Febiger  undertook  publication,  and  doing  this  took  an 
undoubted  risk.  The  ordinary  medical  student  could  scarce  be  exjM'cted 
to  ac(|uire,  still  less  to  master,  the  two  ponderous  i.tmes;  It  was  prob- 
lematic whether  the  more  ambitious  and  advanced  student  and  tlu-  prac- 
titioner would  be  attracted  to  then.  Fortunately,  these  two  volumes 
of  the  "Principles"  were  well  receivtxl,  and  when  after  the  h'w  of  a 
second  edition  Messrs.  Ix'a  &  Febiger  asked  that  the  original  con- 
tract be  fulfilled  and  that  we  afford  a  text-book  which  should  within 
the  covers  of  a  single  volume  eoi..ai'i  the  gist  of  our  subject,  the  loyal 
upport  given  by  them  to  the  previous  undertaking  rendered  it  difficult 
to  refuse.  Their  desire  was  seconded  by  apj)eals  from  colleagues  in 
not  a  few  schools  for  something  which  would  emlxKly  the  main  features 
of  the  former  work  without  its  bulk. 

Let  us  confess  that  we  found  ourselves  in  a  quandary.  We  were 
averse  to  what  might  so  easily  become  an  act  of  commoiii)lace  book 
making.    In  the  larger  work  a  conscientious  endeavor  has  been  made  to 


VI 


I'UKF.UK 


atrnr.1  a  .liir  iin.l  ..nlrml  pn-s.-ntiitioii  <.f  tin-  -iil.jfit  muttrr.  Mt-rrly 
to  opitomizi-  wi.iilil  Ik-  t..  pnMliur  ii  ".ram"  Imm.Iv.  Oh  tlir  otlur  liaial 
tlu-  larpT  work  n-pn'sriiti-H  our  matiind  ii.iicliiMoiiN  rtjianliiin  the 
rt'spt-ctivj-  valnr  t'.  tli«-  ^tu<l.itt  of  miitTal.  systemic,  ami  spt-cial  patliol- 
njry,  aiul  uj)()ii  tli<"  oriU'rly  tn-atim-iit  of  tlu-  ilitTiTriit  st-ctioiis.  From 
that  onl.T  wf  have  mth  iio  nason  to  .i.part.  Sii|.tTfi«i(illy.  tlnrrforc, 
this  t.xt-l>o..k  mii>t  follow  thr  liiu-s  of  tlu-  "  rriiicipl.-.'  must  run 
the  ilaiipr  of  app«ariiin  to  !)<•  an  al.i)n-viatioii  of  the  same.  I.iit  must 
at  tin-  saiiif  tiinr  l.i-  not  an  cpitomr  of  thr  ilitf.n  iit  sections,  liut  a 
M  ,,.(tion  and  .Iw.llinn  upon  what  \v<-  rejianl  as  mo-t  important  for  the 
stn.hnf.  anil  this  when  the  -.nl.jict  is  ^  \  .  t  an.l  the  innnher  of  men- 
facts  an<l  names  \»hich  it  has  Ixcii  the  <  nslnm  to  t-\peet  tlu-  stn.hnt  to 

accpiire  is  so  eon>i.hTal)le,  that  the  tc\t-l k  of  palholoi;\   of  the  past 

has  often    hein   little   hey.aul   a   catalo«ne  of   term-   uith   tlu-   l.riefest 
linkaj;e  of  connecting  Icttcr-prcss. 

lint  facts  and  pht-noinena  and  their  names  an-  only  the  hrieks  with 
which  the  seien<-e  of  im'di.'ine  ha>  he.-n  hnilt,  and  is  still  in  the  imwess 
..f  hnililinj:.     We  ha\(-  to  develop  not  the  men-  hodman,  whose  virtue 
depends  upon  tin-  muni.er  of  l.ricks  he  can  carry.  I.ut  tlu-  en>;ineer- 
arhitect  who,  aecpiaintcd  with  materials  aiul  their  emi»loyment,  knows 
the  use  of  each  particular  rc.oin  or  pa>-ai;e,  knows  why  this  construction 
is  called  for  Iutc.  that   material  there.     If  our  l.nildin-:  he  s(miewhat 
lacking'  in  the  elaborateness  ot  its  decoration,  wv  trust  that  the  founda- 
tions have  l>een  so  devised  that  tlr  n«.ms  ahovi-  will  easily  support  what 
may  eventually  he  i)lacc<l   within  them,  an<l  tiiat  with  no  dan;;er  of 
collapse     It  is  lu.t  the  iniml)cr  (.f  miit  hrieks  that  is  of  importancr  so 
much  as  a  kiu)wledp'  of  tlu-  i^nciples  of  construction.    To  he  hrief,  \\v 
have-  eiuleav.>n(l  first  aiul  foninost  to  make  <'lear  aiul  intelliphle  what 
is  known  coiuernin^t  tlu  deeper  meaniuK  of  nu>rl)id  states,  and  have  iu>t 
hesitated   to  sacrifice  lists  of  data   v>\^\   flu-ir  nanu-s.     The  advanced 
j)atholop>t  naiy  hiok  in  vain  for  i,.  ormaiion  that  will  add  to  his  kiuiwl- 
ed^e  in  jjarticiilar  suhjc-cts;  a  s])ecialist  is  certain  to  find  his  i)articular 
specialty  inadeciuately  treated  as  re^'anis  detail;  hut  to  him  who  says 
that  iniuh  ha>  Seen  omitted  we  dare  re|)ly  that  much  has  heeii  iiu-ludeil. 
The  all-important  matter  is  to  pn>vid(-  and  familiarize  the  student  with 
the  plan  aiul  workinn  drawinjis  of  our  science;  once  he  has  these  in  hi.s 
head  it  is  a  comparativ»-ly  simple  matter  for  him  to  pi.i;eon-hole  meti- 
tallv  lu'w  fact-  into  their  proper  places  as  they  come  lumrinj,'  in  upon  him 
ill  tlu'  wanls  and  dead  house,  in  his  n-adinii  aiul  lectures. 

This  has  Keen  our  aim  and  this  is  our  a])olof;y  for  the  iirescnt  work. 


iL. 


I'l.    hWCh 


VII 


TIm. 


fainili 


;u    w 


itii   till-  pri-vit.iiH  vi)lii'iM"<  w 


ill   n-.' 


.LMii/.i-  that   ««• 


|,„^,.  .l,"|.art..l   littlr  froii.  ti»-   t.-acl.mjj  in 


I  onKr  (tl     "If  first,   that 


upon 


(li-ii.ral  l'atlu>li)>:\ .  savf 


that  there  han  hwu  a.hli-*!  an  lU'iiuMiiary 


■liaptiT  upon  pain  and  its  M^'nifinuut';  on 


tin-  other  hand,  from  the  verv 


fact 


olo^v   \V( 


that  it  is  .liftieiilt  to  Ik.  oriKinal  in  the  treatment  ..f  s,H^m 


l>ath- 


liave 


lMl,on<i  with  ^'reater  etTort  to  pve  an  a.lwiuate  pres«.n 


tatioii  of  oiir  s«(oiitl  part  w 


ithiii  the  -itact-  at  oiir  <hspo>iil 


uih'  to  that 


em 


I  l.av.-  writt.n  it  afr.-sh  with  little  referen.i 


With   like  ends  in   m.  \v    we 


tn  the  eiirli-      .oliime. 
have  diseard.il   most  of  the  i!      tn.tions 


ein| 


,i„ved  in  the  larmier  work,  introdnein^'  soim 


two  hnndu.i  original 


iinravin^s  from  drawings  nun 


\v  l)v  Miss  K.  S.  Carrinnton  fr"">  »•'«■ 


|„.  M.dill  Mi'li-al  Mnsenm  and  in  onr  deiiartment.  an. 


material  in  t 

from  the  collections  o'  .air  recti 

,„,w  of  rittslmrtih,  aii.l  l'rof.-s.)r 


it       l|.'a(;ii.'s  I*rofcss.)r 


Oskar   Klotz, 


I.     iliea.  ii.iw  o 


,f  Harvard.    T.>  these, 


to  o 


iir  coll.  allies 


Drs.  Co 


,Hn  K.  Hnss...  llaiiford  McKce.  an.l  naiiiilt..ii 


\,hitc.  for  their  a.lvice  with  repir.l  t..  si-ccia 


>iil)j 


If. 


ts.  tl)  Dr.  Mac  'e 


Ahhott,  Curator  .) 


,f  the 


Mcdill  Mclical  Mnseiim.  t..  Dr.  Macl-a.lilhi 


,1  I'ittshiirnh.  an.l  n..t  least  to  our  pu 


il.lishcrs.  we  w.nil.l  here  express 


„ur  sincere  thanks  for  assistance  so  wi 


itliiiK'l 


\   rem 


lercl. 


.].  V,.  A 
.1.  Md" 


M.INTHKM.,    I'll: 


■■■ 


CONTENTS 


I'AHT  I 
(MvNKllAL   PATHOLOGY 


('(■11.-  Mild  'I'issiii's 


(;iiapti;h    i 

I\TUI)l)l<  TllKV 


17 


CHAl'TKH     II 

The  Cm  sks  of  Diskasks 

InluTilcil  Disease  -Intrauterine  Disease —Monstrosities  and  Al)norinalitips — 
Disease  of  I'osl-natal  Ar<iiiireiiient  -I'iiysieal  and  Clieiliieal  Causes— 
i:\lrinsie  Iiiloxications -Parasitic  Causes  -Intrinsic  Intoxication.^,  Inter- 
nal Secretory,  Autolysis,  and  Impaired  Metabolism— Predisposition  and 
Siisceptiliility 


CIIAPTKK     III 

Tin;  Miiiih  I)  and  1{i;a(  ri\i;  Pkiickssks 

Iiiflaiiiniation    -Iiifecti'  ii — Fever  -Iinniunity — Syncope,  Sliock.  and  Collapse 
Pain  . 


IIS 


CIIAPTKK     IV 

TlIK    PliOdUKSSIVIO    TlSSIK    CUANOKS 

()ver(irowtli       Keneneratioii  —  'rraiisplantation    -  Metaplasia  —  Tli<'  Tumors 
Proper,  'reralomas,  TeratoMaslonias,  and  lilastomas— Cysts    . 


KSu 


CHAPTKH     V 

Tm-;  I{kc;ki;ssivk  Tisst  k  CnA\(iEs 
iXormal  Histolysis     'I'lie  Deneneiatioiis  and  Inliltrations— Necrosis— Death  2'.M) 


X  COS  TEXTS 

PART    11 
Sri:(  lAI.  AM)   SVSTKMK     PATH(J1,(!(JV 

CMAl'TKK     VI 

'1  HI.  ('auuiovascii.au  Svstkm 

The  Hlood -(2uiiiilil:ili\c  mid  (iuiilil.ilivc  CliaiiKcs— Tliniiiilx.sis  lliulxilisni. 
HciiionliiiKcs  Tlic  lAMiiiliMlic  Sy.siiin  :tiiil  IMciiia  -  Tliu  Heart  (ioncial 
('<insiil(ia(ii)iH  anil  Special  I'alliolouy  -  The  Arleiie.-  ("apiliuries  and 
Vein>  The  l,yiiipliatie  Nes.vels-Hlood-fiirniinn  Organs.  The  I.viiiph 
Nodes,  Spleen,  and  Hone  Marrow  -Certain  Orfiatis  of  Internal  Seerelioii 
-ModilyiiiK  the  MIood,  the  Adrenals,  Thyroiil,  and  I'aralhvroids 


aaa 


CHAl'TKU     VII 

Till';  Hiitii'iUATorn  Svstk.m 

(ieneral    CoiisiihTal  ions -The     Nose— Pharynx    and     Tonsil-      Larynx    and 
Traeiiea-lSronehi    -i.uiins— I'hnini— Mediafitinuiii -Thviiuis        .      .      . 


427 


CHAPTER     VIII 

TnK  Nkkvois  Sv.stjo.m 

(ieii'ial     Considerations  The     Urain  — The     Spinal     Cord—The     Meiiiiiurs 
— Peripheral  Nerves— The  E\e— The  Ear 


473 


CHAl'TEll     IX 

Till-;  I)i(ii;.sTiVK  .Systkm 

The     Moiilh    and     Teeth'   lisophanus— Sto/vaeii  -Intcstims     i'eriloneiini 
l-iver-  Call-Madder  and  iJiicts— Pancreas 


CHAPTER    X 

Tilt;    L'ltlNAItV    SYSTEM 

I'he  Iriiiaiy  I'unclioii     'I'he  Kidney— L'nMers—Hladder. 


.VJi) 


CHAPTER     XI 

The  Rti'uoDLcrivii  Svstkm 

The    Male   Sexual   Ornaiis— 'the    I'einale   Sexual   ( huaiis  -The    I'rodiiets   of 
Conception,  Placenta,  and  Cord— The  Maniniurv  (iland 


630 


CHAPTER    XII 

TiiK  MoToit  AM)  Tecimkntahv  Svstkms 

The    M!isc!es--Te!,dan-<    atid    Tendon    Sheath:-— Purr^a-Tht'    Pi-iifs— The 
•loinls— The  Skill,  Hair,  Nails 


()73 


■iiL 


samm 


A  TEXT-BOOK  OF  PATHOLOGY 

PART   I 
GENERAL  PATHOLOGY 


THAI  TEH    I 

INTRODUCTORY:    CELLS    AND    TLSSUES 

THE   mSTOLOOT   OF   THF   CELL 

TiiK  Ininiaii  hody  is  made  up  wholly  of  cells  and  the  jmnliicts  of 
cells;  it  takes  oriRiii  from  a  cell,  and  carries  on  its  life  by  cell  activity; 
even  its  food  is  not  available  for  its  use  save  by  the  intermediation  of 
cells.  It  is,  therefore,  reasonable  that  in  ^eekinJJ  to  imderstand  the 
iliseases  of  the  human  body  one  should  study  the  diseases  of  the  individ- 
ual cell,  and  not  its  disease  only,  but  its  health.  This  first  chapter,  there- 
fore, is  devoted  to  the  properties  of  the  cell,  and  attempts  to  show  how 
it  is  constituted,  how  cell  interacts  on  cell,  how  a  commiuiity  of  cells 
t'ornis  an  organ,  how  community  reacts  ujxju  community — in  short, 
iiow  t'  cell  is  at  once  a  unit  and  a  necessary  part  of  a  great  aggrega- 
tion ot  uiits.  If  the  cell  be  regarded  as  an  individual,  it  will  be  seen 
that,  like  a  human  Ving,  it  is  born,  grows,  eats,  casts  out  excretion, 
rests,  is  active,  becomes  useful,  learns  the  work  it  is  destined  to  do, 
fills  its  place  in  the  community,  falls  sick,  recovers,  meets  with  acci- 
dents, is  set  upon  by  enemies  in  the  shape  of  infections,  enemies  which 
it  conquers  or  by  which  it  is  overcome,  grows  old,  dies,  and  has  its 
place  taken  by  another  like  it.  So  far  there  is  a  parallel  between  a 
man  and  a  cell;  and  it  may  be  carried  farther.  The  statement  is  made 
upon  good  authority  that  no  man  liveth  unto  himself,  because  a  man's 
ilceds  react  not  only  upon  himself  but  upon  others,  in  however  indirect 
a  way;  so  the  cell,  as  ])art  of  a  comnuniity  (the  organ),  cannot  with- 
draw itself  from  comnnmication  with  its  fellows,  but  will  bear  its  share 
of  tlic  labor  of  the  organ,  and  its  ill  or  well-being  will  react  upon  the 
ceils  that  are  near  it  or  that  depend  in  any  way  upon  it. 
2 


18 


INTRODUCTORY:  CELLS  AXD  TISSUES 


The  cell  in  health  lies  within  the  province  of  the  physioI(<gist ;  b'lt 
the  i)athologist,  too,  ninst  inulerstand,  as  well  as  he  can,  its  properties; 
es]  .  cially  must  he  attempt  to  know  the  cell's  abnormal  states — its 
overfed  state  and  its  starvation,  its  over-activity  or  its  sluggishness, 
the  cell  attacked,  damaged,  killed,  or  the  cell  attacked,  resistant,  tri- 
umphant, the  cell  in  the  growth  of  its  youth,  or  in  the  atrophy  of  its 
age,  the  cell  in  its  life  and  the  cell  in  its  death;  all  these  he  must  study 
if  he  is  to  understand  the  cell  and  its  place  in  the  community  of  the 
organ,  for  with  such  knowledge  only  can  he  gain  a  sound  comprehen- 
sion of  the  disturbed  states  of  the  organs,  and  of  the  bcwly  as  a  whole. 


Fio.  1 

[     (  \ 

^ 

Y^^W^ 

I       > 

"""'■'        J 

rr7 

,          A          I 

/f-r 

Fia.  2 


Vacunlation  of  nurh-i  of  fat  crlls  Fat  cells  of 
retroperitoneal  tissue  stained  liy  hematoxylin, 
and  examined  under  the  high  power,  to  show 
the  nuclear  vacuoles,  characteristic  of  this  order 
of  cell,  o,  nucleus  seen  from  above;  6,  seen  in 
profile. 


Motor  nerve  cell  from  ventral  horn 
of  spinal  cord  of  rabbit.  The  angular 
and  spindle-shaped  Nissl  bodies  are 
well  shown,     a,  axone.      (After  Niasl.) 


The  Constituents  of  the  Cell.— The  animal  cell  consists  of  two  main 
parts,  the  nucleus  and  the  cell  body,  and  even  if  it  cannot  be  agreed 
that  there  is  in  all  animal  and  vegetable  cells,  a  nucleus  in  definite  form, 
we  can  at  least,  say  that  there  is  nuclear  and  cytoplasmic  material. 
In  the  cells  of  man  the  nucleus  has  a  definite  form,  generall.v  round 
or  oval;  a  nuclear  membrane  can  frequently  be  made  out,  and  inside 
this  the  substance  shows  an  alveolar  or  netted  arrangement.  The 
miclear  matter  can  be  demonstrated  to  consist  of  (1)  the  linin  or 
achromatic  (non-staining)  network  in  which  is  deposited  (2)  the 
chromatin — the  material  which  is  stainable  by  nuclear  dyes.  In  the 
si)aces  is  (;?)  the  nuclear  fluid.  Xot  always  distinguishable  are  the 
following:  {a)  The  mirlcuJii.^,  an  accuinulatic.n  of  nuclear  material 
wliicli  stains  ditlVrcntly  to  the  nucleus  at  large,  and  is  j)resumed  to  b 
of  a  diflVrent,  or  at  least,  temporarily  different  comjMisition;  (6)  vacuoles, 
which  are  rare,  but  may  be  seen  in  the  nuclei  of  fat  cells,  (see  Fig.  1 )  and 


i  <iiJL 


BB 


THE  HISTOLOiiY  OF  THE  CELL 


19 


FiQ.  3 


(c)  crystals.    The  last  two  are  products   of  the  activity  of   nuclear 
nietal)olism. 

The  type  cell  has  but  a  single  nucleus;  hut  at  times  two  or  riany 
nuclei  may  be  present,  a  condition  which  may  be  due,  on  the  one  iiand, 
to  division  of  the  nucleus  with  failure  of  the  cytoplasm  to  divide,  or  on 
the  other,  to  fusion  of  separate  cells.  Both  processes  evidently  occur, 
as  will  be  discussed  when  dealing  with  giant  cells. 

Although  we  say  that  Ihe  nuclear  material  is  confined  to  the  nucleus 
proper,  at  times  it  is  found  that  particles  of  chromatin  appear  in  the 
cytoplasm,  and  there  is  evidence  to  prove  that  these  have  been  dis- 
charged from  the  nucleus;  it  is  of  interest  to  note  that  many  so-called 
intracellular  parasites— notably,  "cancer  i)arasites"— are  evidently 
such  masses,  as  again  are  the  Nissl  or  tigroid  bodies  (Fig.  2)  of  the 
cytoplasm  of  the  nerve  cell. 

The  cell  substance  gives  evidence  of  structure,  to  the  extent  that 
one  sees  a  condensation  of  the  cytoplasm  at  the  periphery,  which 
condensed  plasm  is  designated  ectoplasm  and  passes  insensibly  into 
the    main    mass   of    the    endoplasm.    The 
constitution  of  this  endoplasm  is  a  matter 
of  debate,  but  it  may  be  said  to  consist  of 
(1)    a    reticulum,  the    cytoplasm,  in    the 
meshes  of    which    lies    (2)    the    cell    s-p; 
tlicre   are    also    (.3)   the   paraplasmic  sub- 
stances.   The  paraplasm  includes  (a)  food 
jxirtides   ingested,  foreign   or  excrementi- 
tions  particles  that,    being   unassimilable, 
are  to  be  cast  out;  (h)  crystals  or  granules 
which    have   been   manufactured    by   the 
cell;   (c)  the    fluid    contents  of    vacuoles, 
and  (d)  inactive  substances  laid  down  as 
a  frame  work  in  the  cell,  such  as  fibrils  or 
calcium  deposits.     The  cytoplasm  is  the  active  agent  among  ther- 
although  it  must  not  be  "forgotten  that  there  is  also  an  active  part 
in  the  nuclear  material.     Altmann  has  pointed  out  the  existeiice  of 
fine  granules  which  are  called  by  his  name,  but  of  which  the  signifi- 
cauce  is  as  yet  not  understood.    Lastly,  at  certain  times  specially  con- 
nected with  cell  division,  and   preceding  this  process,  a  sentrosome 
appears  which  originates  from  the  cytoplasm.    From  this  centrosome 
run  fine  rays  of  the  cytoplasm,  and  before  nuclear  division  occurs, 
it  divides.    As  to  its  function,  there  is  no  agreement. 

Cell  Connections.— There  is  a  definite  coimection  between  cells, 
although  it  is  not  an  easy  thing  to  prove;  the  botanists  first  were  able 
to  show  that  fine  connections  of  protoplasm  bridge  the  space  between 
cell  and  cell,  and  the  cog-wheel  appearance  of  the  so-called  prickle 
cells  of  the  epidermis  is  due  to  fine  protoplasmic  extensions  ruiniing 
from  one  to  another,  while  the  endothelial  cells  that  line  the  biood- 
\essels  have  like  junctions.    We  can  ev.n  go  so  far  as  to  observe  that 


Cell  bridges  of  "prickle  cells"  of 
epidermis  (From  a  phoiogrcfh  by 
Schridde.) 


20 


ISTRODJCTORY:  CELLS  AXD  TISSUES 


in  tlic  cgjjs  of  seii-iircliiiis,  wlicii  tlic  (clls  cleave  one  from  anotlier  in 
the  S-  and  Ki-cell  stafie,  tine  protoplasniie  threads  reacii  across  the 
interveninj;  space,  and.  in  these,  grannies  can  he  seen  to  streani  from 
one  cell  to  another.  The  detached  cell  is  the  exception,  not  the  ride. 
The  lenkocyte,  it  is  to  he  noted,  is  a  wholly  i?idependent  cell,  hnt  if 
we  follow  the  lenkocyte  downward  into  the  lower  invertebrates,  we 
find  that  the  corresi)ondinjr  cells  have  series  of  connecting  processes. 
The  nerve  <ell  or  neurone  is,  according  to  present  teaching,  wholly 
detached,  at  least  from  other  nenrones.  'Iranting  this,  we  may  say 
that  the  individnal  is  not  a  colony  of  s<  ^larate  units,  as  blocks  in  a 
pavement,  but  a  connected  whole  in  which  the  individuals  are,  in 
general,  semidetached. 

The  Significance  of  the  Cell.~The  cell's  most  noteworthy  character 
is  its  minute  size;  few  cells  are  large  enough  to  be  seen  by  the  unaided 
eye;  when  they  arc,  we  find  one  of  the  following  circumstances: 

1.  The  cell  may  contain  much  stored-uj)  food  material,  as  in  the 
ova  of  many  species;  the  cyt(i])lasm  forms  a  thin  skin  over  the  food 
material  or  yolk,  and  in  this  "skin"  lies  the  nucleus. 

Fio.  4 


«a>      .'•*•-;.<.'• 


; ;~  /  • » ■■- 


»*"•*. 


""'v^^v; 


Cell  briilgcs  of  vascular  cndothcliun 


lAfll-T  Kiilossow.) 


2.  The  cell  may  have  its  prot<  ])lasin  developed  into  radiating  pro- 
cesses, as  in  the  infusoria;  the  luicleus  and  every  y)art  of  the  cell 
remains  close  to  the  surrounding  medinin. 

3.  Tlierc  may  be  great  enlargement  of  the  cell  associated  with  the 
develoi)ment  of  multiple  nuclei. 

It  will  be  noticed  that  in  all  these  cells,  large  though  they  become, 
every  particle  of  the  cytoplasm  is  near  to  the  surface,  if  not  to  the  nucleus, 
and  that  there  is  a  rclation>liip  a.>  regards  size  between  the  inideus, 
the  cytoplasm,  and  the  sum  nnding  medium;  this  relationship  is  deter- 
mined by  the  size  of  the  nucleus.  The  nucleus  is  the  dominant  i)art 
of  the  cell,  governing  the  cytoplasm,  and  this  governance  must  depend 
on  the  contact  of  nuclear  matter  and  cyto])lasm;  so  that  the  nucleus 
which  has  the  largest  surface  relative  to  its  mass,  will,  other  things 
being  ctpial,  be  exerting  the  greatest  effect  upon  the  cytoplasm,  will 
''<■  the  most  active.     If  the  nucleus  be  very  large  it  is  conceivable  that 

r  centrally  situated  nuclear  material  may  be  comparatively  inactive, 


THE  I'llYSlOLOOY  OF  THE  CELL 


21 


M)  tliiit  wf  ma\  say  that  tlu"  small  coll.  wlidse  nuch'ar  mass  is  small 
(•(>iii])arc(l  with  its  surfacr,  will  Im-  active,  and  fittrd  to  siirvivi',  wliiU' 
tlir  <ll  wiiosr  iiucloiis  is  of  UiTnv  mass  and  small  surfaci-,  rolativt'ly, 
will  lie  compelled  to  divide,  anil  so  increase  its  nuclear  surface  or  ho 
handicapped  in  the  race.  This  is  the  princip'.'  on  which  is  develoiH'd 
the  nuiltimicleate  cell. 

If  this  he  true  of  the  interaction  between  luideus  and  cytoplasm, 
it  holds  also  for  the  cytoplasm  and  the  surroundinj;  medium.  The 
external  sur^Mce  of  cytoplasm  can  he  greatly  increased  hy  |)rolonga- 
tion  into  i)n,.e;.ses,  hut  with  the  disadvantaKC  that  some  of  the  cyto- 
plasm is  far  removed  from  the  nucleus;  the  most  economical  form  is 
the  si)herical.  This  indeed  is  the  form  naturally  assumed  by  a  semi- 
fluid or  fluid  mass  suspended  in  another  fluitl  under  the  influence  of 
molecular  inter.iction  and  surface  tension.  We  now  recognize  with 
increasing  force  that  this  surface  tension  is  of  basal  itaportance  in 
cell  activities.  As  the  cell  absorbs  material  and  the  cytoplasm 
increases,  the  surface  becomes  less,  relatixe  to  the  increasing  mass, 
;ind  the  efficiency  of  the  cytoplasm  with  reference  to  the  surrounding 
med'um  becomes  less.  The  cytoplasm  can  now  increase  its  surface 
only  by  division,  and  thus  the  multinucleate  cell  leads  to  the  nuilti- 
cellnlar  organism.  The  multicellular  organism  is  thus  to  be  regarded 
not  as  a  fusion  of  separate  individuals,  but  rather  as  the  optimum 
amount  of  protoplasmic  matter  of  any  particular  oraer  capable  of 
economic  existence  as  a  single  mass  in  any  particular  environment, 
the  maximal  activity  of  such  protoplasm  being  attained  by  nuclea*  and 
cell  division. 

THE  PHYSIOLOGY   OF  THE  CELL 


The  views  that  we  state  regarding  the  nucleus  as  the  dominating 
part  of  the  cell  are  not  everywhere  taught  at  the  present  day.  But  it  is 
fully  established  that,  without  a  luicleus,  growth  and  reproduction  of 
the  cell  caimot  occur.  The  cell  deprived  of  its  nucleus  can  be  the  seat 
of  certain  metabolic  activities,  but  the  cytoplasm  is  progressively  used 
up  and  is  not  renewed,  there  being  no  cytoplasmic  or  luiclear  material 
formed.  On  the  other  hand,  the  nucleus  without  the  cytoplasm  is 
equally  incapable  of  regenerating  the  cell,  for  it  has  been  proved  that 
there  is  a  minimal  limit  to  the  amount  of  cytoplasm  necessary  for 
its  combined  existence.  If  there  be  less  cytoplasm  than  this,  no  growth 
or  regeneration  can  occur,  and  we  add  this  statement  to  what  we  have 
already  sai<l  of  the  dominance  of  the  nucleus,  that  nucleus  and  cyto- 
plasm are  equally  essential,  though  not  of  equal  value  to  the  cell. 
The  nucleus  cannot  treat  directly  with  the  medium  around  the  ci " 
but  requires  the  intermediation  of  the  cytoplasm  for  its  vital  processes. 
We  neid  ;).'ly  refer  to  the  part  played  by  the  nucleus  in  cell  division, 
to  the  series  of  processes  by  which  it  ensures  that  each  daughter  cell 
obtains  its  share  of  the  nuclear  niaterial,  to  the  part  it  plays  in  fertiliza- 


22 


ISTROUrCTOnY:  CKLl.H  A XI)  TISSVKfi 


tioii  and  tlie  repriMliictioii  of  tlio  iiidiviiliial,  and  we  shall  refer  in  some 
detail  to  the  great  activity  of  the  nucleus  in  cell  n)etal)olism.  In  hasing 
its  dominance  ui)on  these  facts,  we  do  not  lose  sinht  of  the  fact  that 
the  cytoplasm  is  ahle  to  manifest  certain  definite,  if  lower,  vital  activi- 
ties, such  as  al)sorj)tion,  respiratit)n, 
mobility,  and  contractility,  aiul 
these  indei)endently  of  mielear  con- 
trol. 

The  Part  Played  by  the  Nucleus 
in  Metabolism.— The  specific  function 
of  certain  cells,  especially  certain  se- 
creting cells,  seems  to  be  governed 
largely  by  the  nucleus.  The  calcar- 
eous frame  of  the  foraminifera  is  not 
formed  if  the  nucleus  be  absent;  the 
anio-ba  cannot  fully  digest,  though  it 
can  kill  living  organisms  if  it  have 
no  nucleus;  the  formation  of  chitin 
in  insect  cells  occurs  only  when  the 
nucleus  is  present,  and  the  nucleus  is 
essential  to  the  production  of  slime  by 
the  amoeba.  In  mucous  goblet  cells  and  in  the  cells  of  salivary  glands 
the  i)rocess  of  secretion  is  accompanied  by  and  probably  dei)ends 
upon  the  separation  from  the  nucleus,  and  that  more  especially  thnnigh 


Fi.i. 

Relationship  of  miclrur  pluj*nia«nnir(«  to 
lymogen  granules  and  »i^vTvtcry  suli-staiu-t's 
of  Becreting  cell:  a,  intranutiear  platJinufloinos 
<  nucleolar  bodies) ;  6,  Krnnulo  (extranurlcar 
plaHinaAonic  or  chromidial  body)  in  ryto- 
plasni.  near  niirjoua,  having  same  atuininK 
reaction,  and  evidently  dischurKcd  from  the 
nu^'leus;  c.  ronversiou  of  same  into  more 
feebly  R'aining  serretory  (prezymonen) 
granules;  d,  further  stage;  lymogen  gran- 
ules about  to  be  discharged  (After  Maxi- 
mow.) 


Via.  0 
< 


/•. >- 


t'>- 


'#"/ 


K 


^\^^r 


.-     T 


DevclopinK  egg  of  Aniuinn  hifida,  sliowlni:  exlnisimi  of  nurlear  mutter.  VminK  oocyte,  the  nuclear 
chromatin  in  the  form  of  scattered  branching  threatla.  The  ilecply  stained  nucleolus  is  seen  in  the 
act  of  ejlruding  cpherules  'clironiidia)  into  the  cytoplasm,      X  i>(X)0. 

the  mideolus,  of  granules,  or  chromidia,  which  stain  deei)ly  at  first 
while  they  lie  near  the  nucleus,  and  stain  less  deeply  as  they  move 
away,  until  they  aj)pear  actually  to  become  the  secretory  granules. 
The  secretory  gramiles  are  either  actually  extruded  parts  of  the  nucleus, 


me  i,A'' 


THK  I'liVSIolAKSY  OF  Tilt:  (El.!. 


23 


(ir  tlio  pnMliictN  of  iiit»TH(ti(iii  iM-twtrii  >iidi  cxtnulivl  parts  and  (rrtain 
(oiistitiunts  of  tlu-  crll  IxmIv.  The  " prt'zx inom-iis"  of  the  cell  are 
Rivi-ii  oil'  from  the  iiueleohis,  and  in  the  cytoplasm  l>eonme  /ymogeiis, 
being  again  given  otl'  from  the  cytophism  as  specific  secretions. 


Section  from  the  liver  of  a  child  that  dii-d  from  acute  sepsis,  to  »how  various  stages  of  karyolyiia 
of  the  f^rst  order:  1,  unaffected  nucleus;  2  and  3.  paler  staining  nuclei,  with  some  swelling  and  diminu- 
tion of  chromatin;  4,  nuclei  still  more  swollen,  the  nien.brane  only  and  an  occasional  nucleolar  mass 
taking  on  the  stain;  5,  nuclei  p-esrnt  a»  little  more  than  unstained  ve.clcs. 

The  formation  of  fat  in  fat  cells  is  evidently  a  tniolear  process,  for 
the  vacuoles  in  their  nuclei  give  the  reaction  for  fat,  and  have  some- 
times l.een  fixed  at  the  moment  of  extrusion  into  tlie  central  fatty 
globule  of  the  cell.  It  is  long  since  the  changes  were  described  which 
the  nucleus  undergoes  in  salivary  cells  during 
and  after  secretion,  and  nuclear  alterations 
have  been  frequently  observed  in  the  ner\e 
cell  bodies  of  vertebrates  after  natural  and 
experimentally  produced  fatigue.  The  changes 
in  fatigue  in  the  Nissl  boflics,  which  are  of 
nuclear  origin,  are  very  noticeable.  In  general, 
it  may  be  said  that  nuclear  changes  within 
physiological  limits,  arc  manifested  by  (l) 
clianges  in  size  and  (2)  alteration  in  the 
amount,  and  (3)  the  disposition  of  the  chro- 
matin. In  pathological  conditions,  still  further 
grades  of  alteration  are  seen;  such  are  reduc- 
tion of  the  chromatin  (krryolysis),  abnormal 
arrangement  of  chromatin,  ledema,  and  swelling  of  the  nucleus,  vacuo- 
lization, nuclear  disintegration  (karyorrhexis),  and  abnormal  discharge 
of  nuclear  material  into  the  cell  substance. 

Summary.— The  following  summary  of  our  conception  of  the  physi- 
ology of  the  cell  n-,ay  be  given:  the  nucleus  is  the  dominating  part 
of  the  cell,  which  cannot  act  save  in  association  with  the  cytoplasm; 


Leukocytes  with  disintegra- 
ting masses  of  nuclear  material 
scattered  through  the  cyto- 
plasm (karyorrheus). 


wi-.<i  .?;■._  *,^^'-.i»r.":L-»e- 


24 


isritoDiiro/cY:  <Ki,i.s  wh  rissi  us 


X\\v  miclnis  imtiat.-s  >;r..\vtli.   rr|.r.Mlii(ti(.ii.  tiiul  ol'tcn   tiiiMti niiil 

n-mts  upon  tlu-  <\  tupliism.  tiikinj;  siil„tiiiic.'s  lr..iii  it  niul  vicldinj; 
snhstaiicfs  to  It,  l>iit  not  acting  .lin-.tly  upon  thr  mt-dinni  wliidi  sur- 
rounds thf  (rll.  The  cytoplasm,  on  tlu-  otlu-r  liand,  takes  up  and  acts 
upon  niattt-r  from  witliout.  and  >;ivfs  out  in  turn  otlu-r  sul.stunccs; 
this  It  (h.es  imrtly  on  its  own  account,  and  i)artly  as  intcmicdiarv  for 
tlic  nucleus.  Thcs.-  acts  it  performs  in  the  proirsses  of  ahsorptioii  and 
n-spiration,  and  it  can  he  mohiie  and  contractile,  as  well.  Lastly 
\ve  only  mention  another  im|)ortant  class  of  activity,  the  prcxluctioii' 
of  orjramc  terments  hy  cell  metal.olism;  these  can  hi-  discharged  from 
the  cell,  and  can  act  as  intermediati-  hodies  hetween  the  external 
meduim  and  the  cytoplasm,  and  can  finally  act,  through  the  cvtoplas,., 
upon  the  micieus. 


THE  CHEMISTRY   OF  THE  CELL 

All  cells  possess,  in  common,  water,  lipoids,  and  |)roteins-  the 
protems  at  least,  are  to  he  extracted  from  all  cells  as  s.u.n  as  they 
iire  dead,  and  exist  m  the  Ii\  injj  cell  as  such  or  as  proteidojjenous  sub- 
stances, which  Kive  origin  to  proteins.  There  are  manv  other  sub- 
stances to  he  found  in  cells,  such  as  salts,  alcohols,  carholivdrates, 
iind  so  on.  and  many  of  these  we  rej;ard  as  products  „f  disintejiration 
<)t  proteins  or  as  goiiij,'  to  be  built  up  into  proteins.  None  of  them 
liowever,  is  common  to  all  cells.  Althoimh  i)roteins  are  dead,  inert 
matter,  and  have  underj;one  change  before  we  obtain  them,  vet  we 
i)elieve  they  are  bound  Mp  intimately  with  what  -e  call  "life."  and 
when  we  refer  to  the  active,  living  part  of  the  .  .  as  the  biophoric' 
molecule,  we  mean  proteidogenous  mattei;  that  is  to  sav,  matter  which 
by  re-arrangement  of  its  molecules  or  satisfaction  of  its  affinities 
becoines  convert,  into  proteins.  The  lipcads  above  mentioned  are, 
as  will  l)e  pointed  out  later,  closely  related  to  the  proteins. 

Proteins  and  Lipoids.  -The  Constitution  of  Proteins.— Proteins  are 
comi)lex  compounds  of  nitrogen,  carbon,  oxygen,  hydrogen,  and  sulphur; 
some,  too,  contain  iron  and  i)hosi)liorus.  So  larfe  and  so  complex 
are  the  molecules  that  in  general  they  are  incapable  of  crystallization 
and  remain  in  a  colloid  state;  s.mu  of  the  simplest  proteins,  it  is  true, 
are  crystallizable,  and  can  be  obtained  pure.  The  henu)globins  (in  the 
I)lural,  for  they  are  multiple)  have  been  analyzed,  and  samples  from 
<liHerent  species  of  animals  'lave  varied  between  C«uIIio98X2ioO,4oFeS.. 
and  (  7i2Hii3o-\ji402i,^Pe.S;  and  they  are  among  the  simplest.  The 
molecules  of  many  i)roteins  are  far  larger,  and  an  average  molecular 
weight  for  a  jjrotein  has  been  estimated  as  l.j.OOO;  it  can  thus  be  under- 
st()od  that  many  i)rotein  molecules  do  not  make  their  wav  through 
anima!  meml)n;ne,  and  do  not  diffuse. 


'  f?'",  life:  Of/  f/i'.  (()  bear. 


TIIK  (  IIKMISTUY  OF  TIIK  CKI.L 


26 


Classiflcation.     We   ^|M-iik  of   pnitcins  ns  free   or  combined.      Vrw 

l>rot('iii>  arc  tli<-  iilliiiiniiis  i>rriiiii  alliiiiniii  of  lilood,  t-^'^;  alhiiiniii), 
the  ^'loliiiliiis  (si'ruiii  ^'loliiilin,  fil>riiioKi<ii).  aiul  the  vitclliiis  (\\w  "volk 
plalr^"  of  v\i\i  yolk). 

Tlic  combined  |>rotciiis  nn-  in  coinhiiiatioii  witli  various  hmlics, 
iiu'liidiii^'  otIuT  proteins.  Hemoglobin,  for  t'xainplt*,  can  he  lirokcn 
u])  into  licinatin  or  more  lururatoly  lifinoclironio>;en  ;in  iron-contain- 
iiiC  liody  with  protein  characters-  and  );lol)iii,  an  alimminoiis  matter 
wiilch,  accordinjc  to  Gamj;ee,  is  not  a  nlobuhn.  The  nucleins  are  com- 
pounds of  protein  and  nucleic  acid,  \vhi<h,  in  turn,  is  a  compound  of 
phosplioric  acid  and  the  so-called  nuclein  bases;  the  miclein  Imses  are 
cloM'l.v  related  to  proteins.  The  nucleins,  attain,  combine  with  free 
proteins  to  make  the  nucleoproteins.  ^'et  other  ])roteins  combine  with 
carliohyd rates  to  make  glycoproteins,  important  amon^  which  are  the 
mucins. 

It  has  been  said  that  if  individual  sjH-cimens  of  proteins  he  analyzed 
they  do  not  );ive  iilentical  pro|M)rtions  of  C,  II,  \,  and  ().  .Ml  of  them, 
however,  may  lie  broken  uj)  into  simpler  Ixxlies,  which,  in  turn,  have 
proteid  characters.  This  is  true  not  only  of  ihe  combined  hut  also  of 
the  free  proteins;  for  exami)le,  proteolytic  ferments  break  down  albumin, 
>;lol)ulin,  myosin,  etc.,  into  peptones  and  albunioses,  which  are  still 
]>roteins  but  with  smaller  molecules;  smaller  molecules  tliey  possess, 
because  they  can  ditl'use  through  membrane;  the  jjcptoues,  etc.,  are 
dcj;radatiou  i)roducts  of  the  proteins,  and  we  can  infer  that  the  ordinary 
protein  molecule  is  a  combination  of  like  molecules,  and  is  thus  an 
examj)le  of  polymerization,  or  the  formation  of  a  larj;e  nutleculebv  the 
ajrj;re;;ation  of  a  series  of  smaller  ones  which  are  alike,  or  of  like  order. 
The  peptones  and  allnunoses  atl'ord  a  still  further  series  of  degradation 
products,  the  >;roup  of  the  amino-acids,  which  tojiether  make  up  about 
three-fourths  of  the  albumin  molecule.  These  amino-acids  are  first 
cousii;s  of  tlie  fatty  acids,  are  indeed  fatty  acids  with  qualities  tendinp 
to  be  basic  by  the  addition  ol"  Nils  molecules;  which  a^ain  by  iiydra- 
tion  or  by  the  addition  of  an  Oil  molecule  become  the  hydroxyl  fatty 
acids.  These  amino-acids,  always  j)resent  as  degradation  jjroducts  of 
!)rotein,  are  in  reality  the  basis  of  protein.s;  th"  protein  is  built  up  by 
a  linkinj;  together  of  numerous  amino-acid  molecules. 

Chemists  have  now  been  able  to  obtain  pure,  and  to  study,  a  series 
of  these  amino-acids,  and  have  been  able  to  obtain  optically  active 
forms  of  them,  the  significance  of  which  fact  will  ajjpear.  It  had  been 
noted  for  a  long  period  that  if  a  substance  were  the  product  of  vital 
processes,  it  was  optically  active,  but  if  it  were  synthetically  produced 
by  the  chemist,  it  was  optically  iiuictive.  The  optical  actiuty  of  the 
now  synthesized  amino-acids  indicates  that  they  are,  so  far  as  hiunan 
observation  can  go,  absolutely  identical  with  the  amino-acids  of  the  body. 

T!ie  antiito-acids  arc  amphoteric,  that  is,  they  pi/ssess  both  acid  and 
basic  jjroperties,  acid  by  reason  of  their  COC)H  group  and  basic  by  the 
NII2  groups,  and  it  is  this  duality  of  affinity  that  permits  linkage. 


I>n  iSTHOIHrroRY:  ChlJ.S  AM)   TISSfKS 

To  iis«'  a  lioiiu'ly  siinilc,  Ut  lis  iiniiKiiu'  th«'  plac«-  of  an  iimiiiicacHl  takrii 
hy  a  man.  witli  twi)  artificial  ariii>;  at  tlu'  «iiil  of  niw  is  a  liiM»k  (tlir 
hasic  aHinity),  at  tlu-  nul  of  tin-  otlitT,  a  rinn  (tla-  acid  affinity);  if 
thiTf  won*  a  liirm'  iiitinlH-r  of  such  in»'n  tlicy  c<miI(I  form  a  complete 
circle,  luMik  in  rinn.  li'Mik  in  riuK  tlimut'lioiil  the  entire  ^roup.  If. 
now,  we  imagine  the  children  of  each  man  inmninnon  to  his  coat  tails. 
we  have  a  lar>;e  colony  (the  comiMimid  molecule)  dejHMidinK  for  perfect 
cohesion  upon  the  luM-k  and  riiij;  men.  These  rings  of  varying  innnher 
of  amiiUMicuK  arc  tlic  polype ptids,  ami  a  linkage  of  eighteen  individ- 
uals has  heen  experimentally  ohtaineil  '  is  not  even  luwssary  that 
the  links  should  he  the  same  amino-ac.  ■..  just  as  it  is  not  necessary 
that  the  men  he  of  the  same  race.  Tiie.c  synthetic  compounds  prove 
hy  their  character  to  he  all  hut  identical,  if  iiot  identical  with  the 
peptones  of  the  hody. 

Tiic  conception  we  have  here  given  may  he  erroneous  in  particulars, 
hut  we  have  attcmi>ted  to  give  the  idea  tliat  the  comi)lcte  molecule 
is  a  ring,  and  that  ring  we  have  suggested  hy  the  hizarre  simile  of  the 
group  of  men  hand  in  hand  or  "ring  in  hook."  This,  he  it  remcmhered, 
indicates  only  the  simpler  molecule;  the  more  intricate  proteins, 
l)olymerize<l  forms,  are  aggregations  of  such  rings,  and  it  will  readily 
he  seen  that  a  vcr\  slight  change  in  the  iiidividvudity  of  one  sul)-group 
will  change  the  comi)osition  of  the  whole.  Reverting  to  the  group 
of  men  with  the  children  hanging  on  to  their  coat  tails,  we  have  to 
picture  these  groujis  a>  l><  iiig  surromided  hy  a  concourse  of  individuals, 
who  are  constantly  moving  to  and  fro;  such  a  picture,  for  example, 
as  a  hird's-eye  view  of  a  fair  grovniil  would  afford;  these  individuals 
(ions  or  radicals)  as  they  |)ass  a  group  invite  (hy  their  unsatisfied 
affinit>  !  an  individual  of  the  group  to  leave  it,  and  every  now  and  then 
one  of  these  free  indix  iduals  is  impelled  to  attach  itself  to  a  group. 
Ix>t  us  suppose  we  have  twenty  such  groups,  and  this  coiiii)ouiid  group 
(or  giant  moh-cule)  hy  actual  count  has  this  formida :  White2oo,  XcgroMo, 
Indiaiito.  Chineses,,.  If  a  couple  of  children  stray  away  the  group  he- 
comes  whit«>2oo.  negrosia.  Iialiaiisi,  Chinoiw,  and  tlie  group  is  no  longer 
the  same.  This  is  precisely  what  is  occurring  in  the  giant  molecules 
of  the  'oody;  the  arrival  of  a  new  ion  of  foo<l  material,  the  separation 
of  a  few  ions  of  excreted  matter  make  for  the  moment  a  new  aggrega- 
tion, and  these  small  changes  mean  a  ci)nstant  re-arrangement,  and 
constitute  the  inetaholism  of  living  matter. 

Lipoids.  During  the  last  few  years,  the  importance  of  the  lipoid 
in  cell  activity  has  heen  more  and  more  recognized.  Under  this  term 
we  include  those  hodies  which  have  the  common  property  of  hcing 
dissolved,  like  ordinary  fats,  in  ether,  alcohol,  chloroform,  etc.  Nearly 
all  of  the  hudics  having  this  i)roi)crty  are  fatty  compounds,  hence 
the  term  lipoid,  a.ihough  it  is  usual  to  include  here  also  choU'sterin, 
which  has  no  fatty  moiety.    They  may  '«■  ch^sified  as: 

I.  Bodies  containing  neither  phosphorus  nor  nitrogen:  fatty  acids, 
neutral  fats,  sioaps,  cholesterins. 


TliK  CIIKMISTHY  OF  TIIK  SfCLKCS 


27 


pL  .l.olin)  an.1  k.-pl.ali..  (having  tvvn  fatty  aruls  a.al  two  lmst». 
'  w..ii  as  sphiMpmiL-lin.  the  most  important  .onst.tutM.t  of  the  s.. 
liilltil  protaiiuii  of  hra   1  siibstaiicf. 

M.Us.  wliicl.  rrst-mhle  p  uo>i.U-s  i..  tl.fir  comiH.situ.n. 

IV.    H.k1u's   of   fatty   imtiirt'.    i.ot    vft    'inalvze.1,   «•.  f/..   tlu    Ii|m.- 

'''!i;"ont  investigation  in.Hcutes  that  the  lecithins  an.l  ehdesterins 
are  intiinatelv  «ss.H.iate<l  with  the  development  of  protective  sul.- 
.tances  of  the  bcKly  and  the  prodnetu.n  of  immunity. 

The  Chemistry  if  the  Nucleua.-The  com,)«s.tion  of  the  mul  -us 
ditlVrs  from  tluit  of  the  cytoplasm;  it  contains  no  potassmm,  no  curlM- 
l      r f     and,  s,H>«king  Renerally.  m  fats,  hut  un  the  contrary.  .Iocs 
!   nt  h.  phosp'ho'rus  ami  "m«ked"  iron    (that  .s,  iron  "'  «  -n;;>^'' 
•h.„).  which  a  ,,»ear  in  the  cytoplasm  hut  rarely  and  m  small  amo  nt. 
-ria-  proteins  of  the  nucleus  show  some  pecu  uir  cluiracters,  Kastr  c 
iuic.  will  dissolve  ordinary  proteins,  hut  the  nucleus  of  a  cell  is  resistant 
;;.,;.  „ecausc  its  nucleoproteins  consist  .,f  alhumin  and  niK^leiu  ami- 
hi„...l.  and  the  latter  is  resistant.    Nucleiiui  contain  2  to  9  i)er  ct ut 
of  phosphorus,  can  he  split  up  into  albumin  aiul  !^/'"'^''^''"%  •;;."";'  "^ 
a.id,  of  which  there  are  several.     Nucleinic  acid  can  be  .^"rther  d_i>- 
inteiiratcl  into  the  x«ithin  and  ..ther  purin  bases    uric  acid,  xanthin 
Kuanin.  a.lenin,  and  hypoxanthin).    These  derivatives  are  ,m,M>rtant 
'iini,.l'v  because  they  exercise  a  toxic  eflfect  u,x,n  tissues.  esiM^cially 
the  ki.inev,  and  it  is  these  which  constitute  the  drawback  to  a  pro.e.n 
,iiet  in  persons  whose  jmwers  of  elimination  are  imperfect      Ihe  exist- 
ence of  phosphorus  aiul  the  xanthin-base  Rror-.)s  onstitutes  the  ditler- 
,.nce  between  ^he  nucleus  and  other  protopla. -s     These  groups  and 
the   "masked"   iron   and   phosphorus   are   specially   concerned   with 
oxidation,  tlv  importance  of  which  for  the  cell  is  absolute. 

Hefore  leax  r  ^r  this  part  ..f  the  subject  we  would  remoitulate  our 
idea  that  the  •"..iophoric  molecule"  or  mass  is  the  active  part  of  the 
cell;  that  ..  is  a  huge  molecule  a>,,,re,iwted  of  many  large  groups,  of 
which  each,  rnav  be  considere.l  a  ring  of  molecules  with  afhmties  wnich 
are  beinr  satisfied  by  vari<.us  other  groups;  that  some  affinities  are 
c.nstantlv  unsati>fie<l;  that  ions  and  molecules  arc  being  shed  off 
and  taken  on,  and  groups  are  joining  groups  by  new  afhmtics,  that 
groups  arc  breaking  off  and  that  this  activity  means  metabolism, 
means  life.  It  must  be  understood,  too,  that  wh.le  from  moi.. -nt  to 
moment  the  composition  of  the  biophore  may  vary,  the  average  com- 
position over  long  periods  of  time  remains  the  same. 

Enzyme  Action.— We  lay  stress  upon  a  proper  understanding  ot 
pi)7vnie  action  because  we  regard  it  as  In-ing  a  type  of  much  of  what 
we  "call  metabolic  processes  in  the  cell;  we  shall  constantly  recur  to 
the  conception  here  indicated.    We  understand  first  of  all,  that  there 


-mt'-uM^. 


28 


ISTIiODnroHY:  (ELLS  AM)   TISSILS 


an-  tn/yiiio'  in  tlic  ci'll  iind  ciizviiio  (Hit>i(lc  tlic  cell,  tlii'  latter  lu'inj; 
('lal)oriit('(l  ill  tiif  irll  ami  disi  liarjifd.  Kadi  cii/.yim-  acts  upon  a  par- 
ticular sulistaiicc  or  series  of  siiltstimces  in  the  external  inediuin 
j)tyalin  upon  starches,  niakinj;  sugars;  pepsin  upon  proteins  in  an  acid 
inediuni,  niakinj;  ])c])tone>;  trypsin  n|)oii  proteins  in  an  alkaline  niedinni, 
anil  steapsiii  ii])<)ii  fats.  It  is  not  jiossihle  to  ohtain  the  enzymes  free 
from  conihiiiatioii  with  protein  hodies;  as  the  j)rotein  material  dis- 
appears from  till-  solution  the  enzyme  action  disap])ears.  Finally, 
an  extremely  minute  amount  of  combined  enzyme  and  protein  can 
convert  a  maximum  amount  of  fermeiitescihlc  suhstance,  and  yet  the 
enzyme  itself  is  not  used  up;  the  action  does  cease,  however,  when 
the  i)rodiicts  of  fermentation,  have  accumulated  up  to  a  certain  point. 

It  will  seem  straiifre  to  the  reader,  at  this  juncture,  to  say  that 
enzymes  do  not  exist,  hut  such  seems  to  he  the  case.  Enzyme  action 
does,  but  enzymes  as  definite  chemical  entities  in  all  i)rol)al)ility  do 
not.  Enzyme  action  is  an  interaction  hetwecn  a  jjroteidogenous  mole- 
cule, and  a  fermcntescihle  suhstance  present  in  the  same  medium, 
l)art  or  the  whole  of  the  molecule  acting  on  part  or  the  whole  of  a 
molecule  of  the  fermeiitescihie  suhstance  with  the  result  that  a  new 
suhstance  ajjpears-  the  ])roduct  of  fermentation. 

The  Enzymes.-  Enzymes  are  intracellular  and  extracellular;  the 
former  act  in  such  close  comhination  with  the  hiophore,  the  com- 
pound protoplasmic  molecule,  that  we  have  to  conclude  ttiat  their 
action  is  j)art  and  i)ar(rl  of  the  activity  of  the  hiophore.  This  is  proved 
hy  the  fact  that  such  enzymes  cannot  i)e  extracted,  in  fact,  are  not 
existent  in  the  molecule  unless  it  he  alive.  If  this  he  true  of  the  intra- 
cellular eiizynus,  it  is  also  true  of  the  extracellular  ones;  these  enzymes, 
in  fact,  are  free  protein  molecules,  divorced  from  cellular  relationship, 
hut  still  manifesting  a  characteristic  of  life,  viz.,  that  of  l)eing  able 
to  act  upijii  other  molecules  and  cause  their  re-arrangement. 

Some  hold  that  enzymes  act  hy  katalysis,  hut  this  view  we  do  not 
advocate.  They  consider  the  ferment  as  a  hody  i)o>M'ssing  active 
moleciibir  vibration,  so  that,  in  ajijiositioii  to  molecules  of  the  fcrmeiites- 
cii)le  ^'.ll)stance,  it  communicates  to  them  its  vibration  with  the  result 
that  their  particles  are  shaken  into  a  new  arrangement  and  the  fer- 
meiitescihie becomes  the  fermented  substance.  This  is  the  explanation 
given  of  the  process  by  which  finely  divided  platinum  converts  hydrogen 
peroxide  into  water  and  ox\  gen,  and  this  process  is  katalysis.  A  more 
satisfactory  explanation  of  ferment  action  seems  to  be  that  exem])lified 
by  making  sulphuric  acid  from  sulphurous  anhydride  by  the  mediation 
of  nitric  aciil;  the  nitric  acid  gi\cs  up  an  atom  of  oxygen  which  con- 
verts the  siili)hurouH  anhydride  to  sulphuric  acid,  thus: 


H2SO, 


HNO.,     =     HjSOi     +    IIN()2 


Til  iinviiil  i()nfil..-i()ii  ui'  i'iii|il(i\  llic  liiiii  tnii/iKi-  III  (U'Mniiaif  ihosc  fcrinoiits 
wliicli  iirc  pripdiiccd  by  the  livinjj  cell,  to  distinguish  tiiciii  frinii  inorganic  fcnnents, 
e.  y.,  gold  and  piutinuni. 


EXZYMK  ACTIOS 


29 


Tlic  nitrous  acid,  so  formed,  exposetl  to  tin-  air,  coiiil)iiies  with  its 
oxygen  and  forms  nitric  acid,  thus: 

HNOj    +    ()     =     HNOj 

Theoretically,  a  single  molecule  of  nitric  acid  can  convert  an  infinite 
nunil>er  of  nioJecnles  of  sulphurous  anhydride  into  sulphuric  acid  and  at 
tlie  completion  of  the  action  (if  infinity  could  he  completed)  still  exist 
as  a  molecule  of  ii'tric  acid. 

In  this  process  there  are  three  factors— the  suli)hurous  anhydride 
represents  the  fermentescihle  sul)stance,  the  oxygen  the  fermentator 
or  complement,  and  the  nitrous  acid,  which  alone  is  i)resent  in  both 
reactions,  the  ferment.     The  process  can  he  represented  as  follows: 


.-■liiinii  "f  f,Tinrnt-like  ...lion  of  nitroiM  oxi.li-  in  the  formation  ..f  sulpl.urio  ai'iil  from  siil- 
|,l„ir..us  ;,nlivclricl.>.  The  coniplcte.l  cirrlf  rrprpa.-nts  tl.i'  su.T.'ssivi-  .•.tuKi's  of  activity  of  the  UNO; 
n.olorulo,  first  iittadiinc  to  itwlf  ao  O  inolpcule  from  an  O,  combination,  and  then  yiol.ling  this  to 
an  un..ati.=ficil  II  ..-;0,  molecule  To  the  left  of  the  (Imuran,  it  is  souiJesteil  that  the  .ither  O  molecole 
hlHrate.l  from  the  O,  c.mhinaiion  may  also  comhitie  with  an  IIw.SO.,  mol,.cule  to  form  a  second 
molccii!''  of  .sulphuric  acid. 

If  instead  of  the  hodies  in  the  ahove  picture,  we  consider  that  we 
are  dealing  with  protein  molecules  with  their  unsatisfied  affinities,  we 
can  conceive  the  process  as  heing  instigated  hy  their  unsatisfaction 
and  concluded  l>y  their  satisfaction.  Knzyme  action  is  one  form  of 
the  interactivity' of  the  l)iophores.  This  heing  so,  one  of  our  com- 
pouiitl  ])roteiii  "molecule-  may  he  intermediary  hody,  or  it  may  he 
tVrnicntc^cihlc  luhst.'nice:  or.  since  each  iiulividnal  ])art  of  the  huge 
ring  has  got  its  own  peculiar  characters,  and  its  own  \msatisfied 
atfiiiities,  the  same  huge  molecule  may  he  in  a  sense  both  at  the  same 


■PP 


■Vj?'- 


30 


ISTIiODVVTORY:  CELLS  AM)   TL'<sri-:S 


Umv.  If  we  consider  tlie  l)ioi)li()ri'  in  activity,  reacting  thus,  let  lis 
say,  with  proteins  in  the  food  and  <lischarginj;  fewer  inetal)()lites  than 
it  attracts,  \vc  find  it  getting  gradually  hirger.    This  is  growth. 

At  this  point  we  may  review  tlie  subject,  ])ointing  out  tiiat  we  have 
now  three  orders  of  ])roteidogen()us  matter  concerned  in  metaholism: 
(1)  Nuclear  matter,  capable  of  metahoiisin  and  growth  in  a  medium  of 
l)r(>teins;  (iM  cyt(ii)lasmic  matter,  capalde  of  indei)eiident  metal)olism 
Init  incapable  of  growth  save  in  combination  with  nuclear  matter,  and 
{'.])  the  free  organic  enzymes,  capable  of  causing  metabolism,  but  inea])- 
able  of  growth.  .\re  we  to  admit  all  these  into  our  conceptioi  of  what 
is  living  matter?  This  is  a  moot  jjoiiit.  For  ourselves,  we  are  incliiu  il 
to  regard  growth  as  the  all-important  property  of  living  matter;  but  if 
this  view  be  accepted,  then  it  may  be  held  that  the  biophores  situated 
within  the  nucleus  are  the  only  truly  living  elements  vimin  the  cell. 
This  is  contrary  to  the  usual  conception  of  the  cytoplasm  as  being  also 
living  matter;  the  cpiestioii  must  be  left  open. 

The  Reversibility  of  Enzyme  Action.  Since  we  count  cn/ymc  action 
so  important  for  an  understanding  <»f  mctai)olisin,  we  must  indicate 
that  it  is  reversible,  and  in  fear  of  making  the  subject  too  cimiplex, 
we  shall  merely  exemplify  this.  The  enzyme  maltase  splits  up  maltose 
(<',..ll...j()ii)  into  two  molecules  of  glucose  (('ollijOel.  but  in  the  test 
tut)e  the  reaction  is  never  complete— there  remains  a  mixture  of  maltose 
and  glucose.  Maltase  really  can  split  up  maltose  into  glucose  or  build 
11])  glucose  into  maltose,  and  so  long  as  the  products  of  disintegration 
or  of  synthesis  remain  in  the  solution,  neitlicr  the  glucose  nor  the  maltose 
can  be  used  iij).  The  enzyme  will  cease  to  ct  when  a  stage  of  e(iuilib- 
riiim  is  reached,  when  the  tendency  to  di  ;  .-egrate  the  one  balances 
the  tendency  to  synthesize  the  other.  This  action  may  be  exjiressed 
thus: 

CisH-On  +  HjO  +  Maltase  ;^  CsHiiOe  +  CellijOe  +  Maltase. 

Maltuse.  Glucose.  Gliiciisp. 

\\c  have  at  the  ])rescnt  writing  evidence  to  indicate  that  all  enzyme 
action  is  potentially  reversible  (althougl;  recently  it  has  been  shown 
that  the  reversed  action  may  require  a  temperature  ditl'erent  from  that 
refpiired  for  tlie  original  action),  and  this  of  itself  is  good  evidence  in 
favor  of  the  supposition  that  an  enzyme  is  not  a  chemical  entity,  but 
ft  mnjiiKj  state  of  not  iaf act  ion  hit  mm  the  affinities  <if  two  mohriilrs. 
What  was  meant  in  saying  that  the  enzyme  as  an  entity  does  not  exist 
may  now  be  l)etter  understood.  Equilibrium  and  arrest  of  enzyme 
action  'xciirs  when  the  products  of  that  action  accumulate  up  to  a 
ee-lain  i)oint,  while,  if  the  i)rodiicts  be  removed,  it  goes  on  until  all 
the  fcrmentesciblc  substance  is  used  up.  In  the  alimentary  canal,  tlie 
products  of  action  of  the  various  extracellular  enzymes  are  absorbol, 
finally  riiicliing  the  iyiiipli;  iii  lit-altii,  thus,  tlsr  protciii:-,  -tarchcr-,  fttt'^, 
and  other  food  substances  becon  e  fully  disintegrated.  In  the  cells, 
the  action  of  the  intracellular  enzymes  occurs,  and  its  extent  is  largely  a 


\()\-pi{(>ri-:i.\  cossTiTrEXTS 


31 


inattiT  of  (litVusioii.  Tako,  for  example,  the  plyeoKcnic  activity  of  the 
liver  cell.  If  the  cell  in  its  metal)olisiii  has  burnt  up  the  <^\uvosn  it  has 
and  heeonies  deficient  in  carhohydrates.  more  jjhicose  will  diffuse  in; 
the  ferment  in  the  cell  will  synthesize  this  to  frlyco};en.  and  will  con- 
tinue so  to  do  till  there  is  a  local  ecjuilihrium  hetwcen  the  intracellular 
j;ly((>f;en  and  su}iar.  Glyconen,  heinf;  insoluble,  remains  in  the  cell,  stored 
up.  There  it  remains  until  one  of  two  tilings  happens:  until  either  the 
ceil  i3  using  up  ghicose  faster  than  gluc(»se  can  diH'use  into  the  cell  from 
tlie  lymph,  and  the  glycogen-glucose  equilibrium  is  destroyed,  w  hen  the 
re\(rsi-  enz.vnie  action  begins  to  break  down  glycogen  till  so  much 
glucose  is  formed  that  the  equilibrium  is  restored,  or  until  the  ghicose 
ill  tlie  Ivmph  is  reduced,  by  the  tissues  using  it  up,  faster  than  the 
iiliinentiiry  tract  supplies  it,  to  a  point  below  the  amount  in  the  cell. 
If  this  happen,  the  glucose  bein  soluble,  diffuses  out  into  the  lymph, 
and  the  glvcogen-glucose  equilibrium  is  again  destnned;  the  ferment 
action  will"  break  down  glycogen  again,  and  if  the  equilibrium  be  not 
restored  by  a  fresh  supply  of  glucose,  the  glycogen  of  the  cell  will  be 

used  lip.  . 

This  process  we  have  just  described,  essentially  an  enzyme  i)r()cess, 
is  rciilh  what  we  have  been  accustomed  to  call  metabolism;  the  cell 
e(|uilil.riiim  de|:ciids  upon  the  enzymes  in  the  cell  quite  as  much  as, 
..r  mure  than  upon  the  material  absorbed.  If  the  enzymes  of  the  cell 
lie  interfered  with,  the  essential  agent  in  absorption  is  lacking,  and 
we  find  disturbance  of  metabolism.  As  free  enzymes  in  the  cell  are 
a»()(iate(l  with  discharge  from  the  biophoric  molecules  forming  the 
iHiclcu^.  we  see  how  the  foreign  agents  of  disease,  by  disturbing  the 
biophore,  strike  at  the  very  foundation  of  metabolism,  nutrition,  and 
the  well-being  of  the  body.  i      ■  i 

Non-protein  Constituents.—Water.— Cell  activity  is  associated  with 
the  i)resence  of  water,  water  being  the  medium  in  which  metabolism 
(.(■curs.    If  the  amount  of  water  be  reduced  below  a  certain  percentage, 
hitencv  of  activity  supervenes,  and  if  the  water  be  removed  entirely, 
in.iieciilar  death;  60  per  cent,  of  the  human  body  is  water,  and  SO 
!)er  cent,  of  certain  organs,  such  as  the  kidney.    The  average  cell  of  the 
Ininuin   ixxly  may  be  considered   as  seven-tenths  water,  and  three- 
UMitlis  proteins  and  other  constituents.   It  is  still  debated  whether  living 
matter  is  existing  in  a  soluble  state  in  water,  or  as  solid  undissolved 
molecules  suspeiide<l  in  a  fluid  medium.     As  to  whether  the  cell  is 
ru|uid  or  solid,  it  may  be  said  that  the  relation  of  molecule  to  molecule 
is  variable,  and  yet  at  times  is  re'atively  fixed;  the  truth  is  that  proto- 
])liism  is  colloidal,  that  is,  the  molecules  are  so  large  that  they  cannot 
enter  i:erfectly  into  sulution,  and  as  a  colloid  it  possesses  many  of  the 
properties  of  a  li(piid  together  with  the  persistence  of  form  charac- 
teristic of  a   solirl  body.    Our  idea  of  a   solution   is  that   tlie  niole- 
i;i!c~  of  tlu-  di---<>!\<'il  lindy  lie  in  the  interstices  of  the  solvent-  in  a 
colh.id,  prntoi)lasni  for  instance,  we  have  to  imagine  the  molecules()f 
water  as  lying  in  the  interstices  of  the  huge  protein  molecules.     The 


5!i 


32  ISTRODUCrORY:  CKLIS  AM)   TISSIES 

question  is  ,.f  importance   lH-<anse   ..f   Nvl.at    we  know    of  ionization. 
A'hen  NaCl    for  instance,  is  .lissolve.l  in  water  some  ot  the  molecules 
becme  •lissoeiate.l  into  Na  and   CI   and  these  free  constituents  are 
..harued,  son.e  with  positive  electricity  (anions),  an.l  s..me  with  ne^'ative 
kSon;);  these  ac!  as  separate  n.olecules,  and  n.ay  he  attracted  l.y 
molecules  or  l.v  other  i<.ns  havini:  an  oi.pos.te  char«e.     By  URTeasmK' 
^l^^e  diluti.m  all  the  molecules  n.ay  be  thus  ion,/ed.     Mable  ehe.n.cal 
c-omponnds  are  ma<le  by  the  union  <.f  ^'•'^^''''"r  ".V^'^f  "'-^^J'^T 
and  the  ener;.n  repres.-nte<l  by  them  is  neutrah/e.    or  liberate.l.    buch 
0  mpounds  may  be  brok.-n  up  In    heat  or  electr„-.ty  or  by  solution 
.„ul  the  ,lissociate<l  ions  are  rea.ly  for  tresh  chemical  combination, 
'the  assimilation  ,.f  foo.l  by  the  cell  .lepends  ui.oi,  the  separation  and 
re-arraniiement  of  ions.     If  this  is  not   to  be  accomplished  by  heat 
it  nnist  be  <lonc  by  soluti..n.  and  water  becomes  an  essential.    Knzyme 
action  is  larselv  acc.mplished  by  hydrolysis,  and  the  setting  tree  of 
active  hvdrogeil  and  h>  .Iroxyl  ions  in  a  watery  solution,  and  these  ions 
are  most  important  in  the  prooess  of  metabolism. 

Simple  Salts.-  Certain  salts  without  being  built  up  into  the  protein 
„,.,kH..le  are  obvi.n.sly  essential  to  the  cell,  for  the  protein  molecn  e 
does  not  exert  its  activity  in  a  pure  watery  medmm,  hut  ni  dilute 
saline  solution.     The  salts  usuall.-  met  are  chlorine  salts,   alka hue 
rirbonates.  phosi.hates,  and  sulphates,  and  salts  of  the  alkaline  earths, 
esneciallv  sodium,  p..tassium,  ammonium,  calcium,  and  magnesium. 
We  know  little  ah..ut  their  disposal,  hut  we  assume,  from  the  mnuite 
nnantities   present,  that   they  probably   are   mostly   <  issociatetl   into 
their  ions  and  so  help  to  promote  activity  ot  nietabohsm.      i  he  dis- 
sociation of  salts,  an.l  their  building-up  into  the  hiophore  an-  accoin- 
nuued  hv  various  phen..mena  which  we  call  endosmosis  and  exosmosis, 
which  is  the  .litVusing.  in  or  ...it  ..f  the  cell,  of  water  an.l  salts  in  s..  utmn. 
\  salt  oi  high  concentration  in  the  cell  will  pass  out  ot  the  cell  to  a 
mclium  where  the  oncentration  is  h.wer,  an.l  vice  versa    and  at  the 
same  time  a  corre.'tive  reverse  passage  ..f  water  oc.M.rs.     I  he  colloidal 
cell  substan.^e  is  sufficiently  permeable  t..  all.nv  the  m..le.-ules  ot  the 
salt  in  solution  to  pass.     We  believe,  t....,  that  c.  loi.ls  ot  .  irterent 
compositi..n  .litfer  in  their  permeability,  an.l.  ther.'h.re    m  the  time 
renuirci   for  the  passage  thr.mgh   them  ..t   s..lutions       I  Ins  relative 
impermeability   ..f  the  c.Uoi.lal   skin    (ectosarc)    ..t    the  <e  1   ex,.lains 
whv  the  huge  protein  nmlecnles  are  kept  m  the  cell  while  the  sma  ler, 
partlv  .liss...'iate.l  ones  can  escape.     There  are  s..me  ot  these  which 
ire  aim. .St  small  en.nigh  t..  escape,  an.l  their  retention  .lepends  ..n    he 
sfite  of  the  cell  in  relati..n  t..  the  external  me.lnun,  .lei)en.ls  up.m  the 
nature  ..f  the  cell  membrane  an.l  upon  its  surface  tensu.n.    .\n  example 
of  this  is  f..un.l  in  the  re.l  corpuscles,  which  U.se  their  hein..globui  when 
the  salt  in  a  salt  -olution  n-aches  (».47  per  c.-nt.     If  the  osmotic  pres- 
sure he  less  than  this,  salts  .litt'use  out  an.l  water  in,  till  the  ectosarc  is 
rupture.1   an.l  the  henmgl.ihin  is  ,liss.,lve.l  in  th.;  surr.nin.ling  medium 
•m.l  colors  it      Hut  cornnscles  d..  lu.t  l..se  their  hemoglobin  till  the 


r.\  RUnU  YDRA  Ti:S—FA  TS—SOA  PS 


33 


.,^in(.tic  pressure  is  iiiiieh  lii^'l.er  tliim  tlie  tonieity  of  the  serum  of 
iiiiiii  (<>.'.»  per  cent,  sodium  ciiloridei.  Solutions  with  au  osmotie  pres- 
sure higher  than  this  are  hyperisctonic,  witli  one  lower,  hypisotomc. 
The  blood  serum  must  he  very  hypisotonie  before  hemo«lobmemui, 
from  passage  of  the  hemofilobiu  out  of  the  cells,  eau  occur  purely  from 

this  cause.  . 

Carbohydrates.  Free  carbohydrates  as  such  do  not  enter  mto  the 
composition  of  the  bioi)hore,  and  when  found  in  the  cell  are  true  metab- 
oUtes;  thev  have  been  or  are  ready  to  l)e  dissociated.  It  must,  how- 
ever, be  rt'calied  that  the  dissociation  of  nucleic  acid  yields  a  pentose 
iMigar)  according'  to  Levene  and  .lacol)s.  a  hexose  ac'cordinj;  t()  Steiidel 
and  Halliburton.  From  the  ilissociation  of  sugars  energy  is  liberated, 
and  on  the  contrary  energy  is  conserved  when  they  are  stored  as 
built-up  glycogen  molecules. 

Fats,  Soaps,  and  Alcohols.  This  is  another  grouj)  of  metabolites, 
which  mav  jm-  'biy  lie  s])lit  off  froui  the  cell  i;rotein;  they  are  not 
found  in  the  n't.-lei  (save,  as  already  noted,  that  fat  has  been  found 
in  luielear  vaci.oies;,  and  are  to  be  considered  as  acted  ui)on  maiidy 
by  the  cytoi)lasm.  Certain  cells  are  found  to  contain  insoluble  neutral 
fats  of  which  the  most  important  are  stearin,  palmitin,  and  olein;  these 
fat;-,  aecordirg  to  their  fornmla.  contain  a  very  small  quantity  of  oxygen 
with  a  relatively  large  amount  of  c-irbon,  which  means  that  their 
dissociation  and'  combination  with  abs(.rbed  oxygen  is  capable  of 
netting  free  a  great  amount  of  energy;  hence  their  value  to  the 
cell. 

'I'hcse  come  from  the  food  almost  entirely  as  neutral  fats;  they  are 
<  iniilsified  bv  the  action  of  tlie  bile,  and,  to  some  extent  when  emulsified, 
mav  be  absorbed  by  the  phagocytic  action  of  the  intestinal  epithelium 
,111(1  leukocytes.  Hiit  this  is  by  no  means  all.  It  would  seem  that  free 
liitty  acids  are  to  some  extent  sjjlit  (.ff,  soajis  being  formed  and  glycerin 
liberated;  while  again  there  may  be  actual  solution  of  the  fats  by  the 
cnlloids  of  the  cells  and  body  fluids.    This  matter  is  not  yet  determined. 

The  presence  of  the  fat-splitting  ferment  steapsin  (discharged  by  the 
pancreas)  in  the  intestinal  contents  favors  the  division  of  the  fats  into 
iree  fattv  acid  and  glycerin.  The  latter  is  jjrobably  taken  up  by 
I  he  intestinal  epithelium;  the  fatty  acids  are  partly  dissolved  by  the 
Kile  salts,  but  most  of  them,  in  an  alkaline  medium,  are  transformed 

nto  soaps  of  sodium,  jjotassium,  calcium,  and  magnesium.  As  soajjs 
ihcv  j)ass  through  the  intestinal  cells  and  are  to  be  found  in  the  chyle 

iiid'  lymph  as  neutral  fats.    Neutral  fats  are  rarely  found  in  the  blood. 

\iiile' soajis  commonly  are;  so  it  is  evident  that  a  second  conversion 

Mcciirs;  it  is  as  soaps  that  the  fats  are  ultimately  taken  up  by  the  cells. 

-Microscopically,  the  cells  of  an  orr  .n,  e.  ij..  the  kidney,  may  show 

n  flit  nor  do  they  yield  ft  \y'*\\  to  ordinary  fat  solvents;  yet 

lie  dry  .sul)stancc  "of" such  a  /  -.  v>rds  as  much        '7  per  cent,  of 

at;  this  means  that  the  fats  ;.    ■  not  free,  but  c(mibined. 
Soaps  are  evidently  very  important  as  iin  intermediate  stage  in  the 
a 


34 


INTRODl'CTORY:  CELLS  AM)  TISSUES 


utilization  and  synthesis  of  fats;  lipolytic  and  fat-forming  ferments 
have  heeii  isolated  and  designated  lipases. 

Do  proteins  give  origin  to  fats  or  tatty  acids?  They  probably  do  to 
a  slight  extent,  i)ut  at  |)reseiit  it  appears  as  if  the  fats  of  the  body  are 
almost  entirely  the  fats  of  the  food.  Here  it  is  necessary  to  mention 
the  lecithins,  which  are  almost  constant  constituents  of  the  animal 
cell,  and  forr.j  a  considerable  factor  in  nerve  cells  and  in  the  cells  of 
egg  yolk.  They  have  a  fatty  jx^rtion  indicating  a  relationship  with 
fats;  they  are  nitrogenous  s\iggesting  relationship  with  the  proteins;  and 
they  are  richly  ])hos])horized.  The  last  two  facts  suggest  that  they  are 
cleavage  products  of  the  inicleins,  or  combinations  of  such  cleavage 
products  with  fats.  Parallel  to  the  lecithins  as  protein-fat  compounds 
are  the  glycoproteins-or  protein-carbohydrate  compounds — chief  of 
which  are  the  nuicins.  These  are  to  be  seen  in  the  cell  as  globules 
of  mucinogen,  which  by  imbibition  of  water  become  mucins.  They 
are  modified,  largely  inert,  proteins;  among  them  are  gelatin,  elastin, 
chondrin,  amyloid,  and  mucin,  which  are  poor  in  carbon  and  rich  in 
oxygen,  and  yield  on  dissociation  carbohydrates.  A  few  other  "  albumin- 
oid" materials  occurring  in  and  outside  the  cell  are  to  be  mentioned: 
such  are  the  products  (»f  dissociation  of  I  emoglobin.  such  as  hematin, 
together  with  melanin,  the  pigment  of  the  skin  and  hair,  which  recent 
observations  indicate  are  allied  to  the  lipochromes,  compounds  of  lipoids 
with  protein  derivatives;  these  will  be  discussed  with  the  infiltrations 
and  degenerations. 

GROWTH 


In  all  our  previous  considerations  of  the  biophore  we  have  dealt 
with  ipetabolic  activity,  but  we  have  made  only  passing  reference  to 
-owth.  If  Wf  think  a  little  it  will  be  seen  that  the  growth  of  living 
matter  demands  a  process  whereby  two  molecules  exist  where  there 
was  one  before.  Our  conoeijtion  of  the  bio])hore  is  as  a  ring,  or  a  ring 
of  rings,  and  growth  occurs  by  increase  first  of  the  individual  smaller 
groups  or  rings.  These  grou])s,  from  their  very  inception  present  a 
series  of  unsatisfied  affinities,  and  each  or  any  of  the  molecules  is  con- 
stantly attracting  molecules  of  a  like  order,  and  on  the  first  of  these  is 
built  up  a  second  and  a  third  luitil  the  group  is  complete.  Along  these 
lines  we  can  imagine  the  development  of  a  new  ring  of  which  each 
in«lividual  component  is  the  reflection  of  the  components  of  the  original 
ring:  in  its  turn  this  ring  attracts,  ami  so  builds  up  other  rings  in 
due  order  until  eventually  there  is  produced  a  completed  compound 
molecule,  reproducing  the  parent  molecule.  We  use  the  illustration  of 
the  ring  to  indicate  a  degree  of  completeness;  the  ring  can  break,  it 
is  true,  and  in  its  repair,  be  enlarged  or  be  made  smaller,  or  it  can  join 
with  another  l)roken  one,  but  the  mole-jules  of  the  formed  ring  are 
less  likely  to  be  attracted  away  just  'oecause  they  are  in  a  ring,  i.  e., 
in  a  state  of  relative  completeness. 


GROWTH 


35 


The  Relation   between  Growth  and  Other  CeU  Activities.— The 

c.nsi.lrrati.m  of  this  siibiect  (lenmiids  a  few  words  on  the  dynamics 
of  the  cell.  In  tiie  perfonnance  of  function  of  whatever  kind,  t.ie 
cell  is  a  machine  discharfiiiifj  potential  cnerfiy.  The  body  warmth 
means  that  cells  are  •lil)eratinK'  energy  in  the  form  of  heat;  the  nerve 
rell  liiierates  energv  akin  to  electricity.  On  the  other  hand,  growth 
and  tlie  accumulation  of  new  molecules  demand,  not  the  evolution, 
hut  ti  storage  of  energy,  and  this  comes  from  the  food.  The  proteins, 
carbohydrates,  and  fats  are  carl'on-containing  bodies  the  ultimate  result 
of  whose  decomposition  is  a  >  ielding  of  much  energy.  The  excreta  of 
tlie  organism,  carbonic  acid,  water,  urea,  etc.,  on  the  other  In  nd,  store 
up  comparatively  little,  and  the  cells  acquire  most  of  the  difference. 

Strictly  speaking,  energy  is  not  evolved  in  the  dissociation  of  matter; 
but  dissociation  and  the  "freeing  of  ions  mean  that  combinations  im- 
mcdiatelv  occur  which  liberate  far  more  energy  than  was  lost  in  the 
di'^sociations  of  a  moment  before,  so  that  the  ultimate  result  of  disso- 
ciation is,  paradoxically,  a  storage  of  energy.  The  biophores  are  not 
to  be  compared  to  simple  salts,  but  rather  to  nitroglycerin.  A  blow^ 
dissociates  it,  and  though  there  is  a  theoretical  momentary  loss  of 
energy,  there  is  a  vastly  greater  immediate  i)roduction  of  energy— 
an  exi)losi()n— brought  about  by  the  reconstruction  of  the  ions  of 
C.  (),  X,  II  into  more  stable  compounds.  Dissociation,  then,  tends 
t(.  the  liberation  of  energy,  and  growth,  or  building  up,  to  the  using 
and  storing  of  energy,  the  conversion  of  kinetic  into  potential  energy. 
The  energy  of  the  food  is  thus: 

(a)  Katabiotic,  dissipated  in  the  performance  of  function. 

(6)  Bioplastic,  stored  up  in  the  formation  of  the  complex  biophore, 
i.  e.,  in  growth. 

Van  these  two  contrasted  processes,  growth,  and  the  performance 
of  function  proceed  simultaneously  in  the  cell?    They  can,  as  we  shall 

show.  . 

To  digress  again,  growth  is  an  intracellular  affair,  governed  by  condi- 
tions in  the  biophore,  while  the  performance  of  function  is  a  response 
to  external  stimuli  of  some  kind.  If  the  cell  has  abundant  food,  and 
the  stimuli  to  function  be  strong,  all  the  acquired  energy  may  be  used 
up  at  once,  and  no  growth  ensue.  If  the  stimuli  be  yet  stronger,  all 
the  food  energy  may  be  used  up,  and  the  cell  substance  be  dissociated 
to  sujiply  the  further  energy  required.  If  the  food  energy  be  little,  the 
I  cell  may  require  to  use  up  its  substance  to  provide  the  energy  needed 
for  function.  There  is,  however,  a  grade  of  adequate  food  supply  and 
of  moderate  external  stimulus,  in  which  the  dissociation  of  the  food- 
stuffs provides  more  energy  than  the  cell  is  called  on  to  dissipate  and 
the  surphis  is  used  in  growth.  The  development  of  muscles  under 
proper  exercise  illustrates  this.  Conversely,  with  adequate  food, 
and  not  enough  activity,  muscles  do  not  develop,  but  the  contrary; 
a  certain  optimum  of  activity  is  necessary  for  the  maintenance  of 
nutrition  and  of  growth.    There  are  apparent  exceptions  to  this,  in 


a?  -=  >.»,  ■^i^aF'^'^B^-' 


36 


IXTRODrcTfiin':  CF.IJ.K  .1  V/>   TlSSl'KS 


the  I'liiliryn,  in  tiiiiinr  ^'rnutii.  an 


I  in  the  Inct  that  undtT  cxenist' and 


ailc(|natc  nutrition  tlicrc  i^  a  limit  licyoial  wliidi  ^Towtli  cannot  >;o. 
Whereas  j^rowtli  and  function  liavc  tinis  a  definite  rclationsliip,  there  are 
fireninstanccs  nndcr  wiiich  >;ro\\th  is  (piite  in<lei)endent  of  function. 
Active  assiinihition  and  ^rowtli  with  littU'  functional  activity  char- 
acterize the  euihryonic  ami  fetal  stages  of  existence.  The  more  the 
cells  hecomcditl'crentiatcd  (for  their  i)roi)er  function  in  ditVereut  organs), 
the  less  capacity  tlu'y  show  for  ^'rowth  and  the  more  for  katahiotic 
activity. 

(Irowth  of  the  cell  and  <if  the  individual  ])rn>;resscs  until  the  volume 
of  the  cell  (and  of  the  individual;  reaches  the  point  lieyoud  which 
increase  in  mass  is  not  only  imeeoiiomical,  hut  harmful.  There  is  a 
relation  lutweeii  surface  area  and  mass,  and  when  the  mass  exceeds 
a  certain  amount,  the  surface  area  is  too  small,  and  assimilation  and 
discharge  are  hindered.  The  c<'ll  has  now  the  alternatives  of  cell  divi- 
sion (hy  which  there  is  a  rapid  increase  of  surface  area  relative  to  inass) 
or  of  lessening  its  mass  hy  the  ])erformancc  of  function,  that  is,  of 
dissociating:  some  of  its  cell  sulistance.  As  long  as  the  cell  or  the 
individual  is  helow  the  economical  ratio  hetween  its  mass  an<l  its  sur- 
face area  (relative  to  its  external  medium),  it  chooses  the  first  (cell 
division);  as  this  ratio  is  apjmiached  it  tends  to  employ  the  second 
(functional  activity). 

The  size  of  the  individual  is  thus  a  function  of  the  constitution  of 
the  hiophores;  it  is  the  expression  of  the  oi)timum  economy  of  inter- 
action hetween  the  l)ioi)liores  anil  the  external  medium.  (Irowth  of 
cells  and  i>f  individual  continues  till  this  optimum  is  reached.  In  the 
dcvelo])ed  cell  there  must  lie  a  constant  alternation  hetween  growth 
and  functional  activity;  in  ]!erformiiig  function  the  cell  dissociates 
some  of  its  sulistance,  and  falls  helow  the  state  of  oi)timum  efficiency, 
and  it  is  in  a  juisition  to  take  u])  new  matter,  and  grow;  Weigert's 
statement  is  "the  katahiotic  use  of  material  in  function  removes  the 
ohstruction  to  growth." 

Physiological  Inertia  and  Habit.  .\  wheel  set  s])i:ming  continues 
to  s])in  iifter  the  haml  is  witlnlrawn;  a  gland  stiimilated  to  secrete 
contimies  to  secrete  after  the  stimulus  is  removed.  .\  resting  muscle 
continues  to  rest  (during  the  Icifnil  jicridd)  hefore  it  acts  in  response  to 
a  stinmlus.  The  cell,  like  matter  in  general,  tends  to  continue  in  the 
state  in  which  it  is,  whether  of  rest  or  activity.  This  inertia  is  the 
jirecursor  of  habit.  .\  cell  stinuilated  to  ]»erform  an  act.  continues  to 
perform  it  after  the  stinmlus  is  removed;  on  a  second  occasion,  a  slighter 
stinmlus  suffices  to  make  it  rejjcat  the  act,  until  a  period  is  reached 
when  a  niininnim  stimulus  will  ])roduce  an  o])tinHmi  reaction,  and 
the  cell,  tending  to  emi)l()y  its  energy  in  one  ])articular  direction,  tends 
to  lessen  its  acti\ities  in  other  directions.  It  hecomcs  adapted  to  its 
work.  OiK'c  a  eel!  st.".rts  to  grow  it  has  a  ten<lency  to  (,'ontinue  to  grow- 
rather  than  to  jierform  t'lmction,  until  its  increased  size  and  increasing 
tension  and  other  external  stimuli  attain  such  power  that  it  is  com- 


■Hi 


TlIK  f^TATKS  or  (KLl  MTlVm' 


37 


♦  ..pt.wl    is  iu»t  to  roiitimie. 

,...ii...i  t..  f-..ti m-.  'Hns  •;-";;;;^;;:  .;^;;::;  !n;..oi .» ^<^  -- 

\v..  l.av.   tlms  .tt.-.ni. te.1  to  >1  ON  th         J^  ^^  ^.^.^^^,,,,  ^,      ,,,. 

'-»  '•■'"""■^  •"";•■  *    ^Hn!:;  V    hv  Si    tlu.  energy  that  is  put  -nto 

ruxvtii  iM'coiiifs,  at  tlu  prop  i 
^,f  fuM.'tioM  an.l  a  .•o..t.nuan.'e  of  tht 


RESERVE   FORCE 


All  imp^rtiiut  ( 


■iiaracttr  of  living  " 


attrr  IS  w 


hat  is  tiTim'tl  reserve 


force;  upon 


it  (hMHMi.ls  thf  proi'i 


.f  hi-al 


lui^;. 


Just  as  a  \va 


ill,  a  hridttt" 


or  a 


l,„iU.r.  l.iiilt  ou  souiK 


il  mei'hauical  priunp 


IS  an 


ihlc  to  stan< 


il  a 


strain  several  time: 


Uri-ater  tlian  it  is  on 


liuarilv  expected  to  earry 


hc  "factors  of  safety    t 


It 


there 


,ftheeiiniueer).soarethece 


l)f  tluM 


)rnauism; 


is  a  larj;e 
thev  exert  ww 


reserve  i 


,f  force  or  energy  hi 


them 


liT  normal  conditions. 


Illustratious  o 


nl)o\ 
f  th 


that  whicli 


are 


knoNVi 


to  cvervone. 


The  patient  \yho  see 


■ms  so  wta 


k  that  he  can  scare 


•ely 


his  arm  may 


raise 
heart  can  ' 


JuTome  in  .lelirium  a  m 


,tch  for  two  men. 


The 


lo  thrice  its  norm 


ill  work  without  overstrain 


three-(iuarters 


ic  ran 


of  tl 

it>  iiurp< 
injury  to  t 


l.l)it"s  hver  m 


ise;  t 


i\  he  remove( 


,1.  and  the  reinainiiif;  (luart 


he  whole  of  the  spleen 
ilth 


.f  tl 


lie  111) 


ifj  ma\ 


iv  he  exciset 


er  serve 
I  without 


he  animal's  health 


111  the  last  case. 


ther  related  tissue 


take  11!)  the  functic 


)I1S   o 


etr 


itv;  yet  vieariou. 


activity  is 


,f  the 
a  pure 


,,„,  .M-rcisins:  a  f^^)^';^^  "i;  compensatory  -  -        . 
example  of  reserve  force,     ^luli  also  v  i„.,rv  excretion; 

nim,  will  suffice  ^^  ^^^'^:T'.Z^^^  "P  th^  work  of  its 
wen  in  the  hrain.  one  ot  a  pa  -  .J^-  '^^  ,,„,,,,,,,/  ..  t.  possess 

.U.troyed  fellow.  In  shor  ^'^^^  ,,^  re.rne  force.  This  reserve 
;,  ,„.,  „f  i,.f,.nctn„.  on  ';^:;;  ^^  ,'  ^  ^,,.1  of  immunity  f.  .lisease. 
,„r....  'ies  at  the  n.ot  ..t  the  »H^>ll%  ••'  •'  ^  ,,vsioU,pcal  inertia.     I-de 

U..,.rve  f..rce  is  yet  one  more  "^     'J.,,,\,nnternal  con.l^ 
ha>  hecn  defined  as  the  c->ntnumus  .  3^  m  "t     ^^  ,, 

:;;T;;::-;;:u;;mS:i:::;.fr^r^^^^^^^^ 

THE  STATES   OF  CELL    ACTIVITY 

c.nstitute  cell  disease.  ,    ■         ^,jp  accumulation  of 


38  INTRODUCTORY:  CELLS  AND  TISSLKS 

relutivelv  little   stimulati..n  pass   int..  an   iiu-rt,  latent  state.     Tliese 
el  s    with  lack  of  sti.nulation,  atrophy,  «n.l  son.e  c.f  »->  -t-l 
disappear.     Not  only  .h«s  this  occnr  w.th  redum  ant  cells,  hu    oe 
S  normal  cells  nn.ler  al.n..rnml  conditu.ns;  th.s  can  he  uell  seen 
h     he  atrophv  which  an  innnol.iiized  leg  underRoes;  a.u    the  actua 
san  trance' of  cells  is  seen  in  the  cases  in  which  the  lower  ino  ..r 
Z  es      roplly  and  disappear  as  a  resnlt  of  lack  of  stnnu  at.on 
from  the  upper  ones,  in  cases  where  the  npiK-r  ones  are  destroyed. 

>  Vegetotive  Activity.  Cells  in  the  ,.roc^.ss  of  active  growth  present 
certain  well-marked  characters.  The  nuclei  are  large  roimd  or  oval 
stall  ng  <leeplv;  paraplasmic  gran'.des  are  not  prominent;  the  cell  body 
s  ind  or  oUl  Cells  ..f  this  character  are  prone  to  repnxluct.ve 
activ  t  and  have  l,een  called  embryonic  cells.  The  name  is  not  a  good 
one   becalJse  such  cells  occur  at  all  life  periods,  and  a  better  term  for 

'T^rxS'Vctty.-Cells  in  functional  activity,  show  signs 
of  differentiation  acconling  to  their  specific  unction;  in  r^^f^J' 
nerve  cells  the  cvtoplasm  is  highly  elaborated;  in  gland  cells,  there 
are  paniplasniic  d'eposits,  in  the  form  of  granules  or  globules;  the  nucle 
are  not  large,  and  their  staining  differs  according  to  the  stage  of  cell 

''4'  Hyperactivity  vathin  tiie  Limits  of  tiie  Reserve  Force  of  the 
Cell  -When  increased  stimulation  is  accompanied  by  adequate  nutri- 
tion   the  functional  activity  of  the  cell  is,  to  a  certain  extent,  accom- 
nanied  bv  growth,  and  this  constitutes  hypertrophy. 
^5   Excessive  Functional  Activity. -When  the  cell  work  is  ex  reme 
the  energv  used  up  exceeds  the  supply  fn.m  the  food,  the  paiapla.m.c 
m^teihil'disappeaJs,  the  protoplasm  is  .lissociated,  "''d  f^^^^  ™" - 
be  continued   the   cell  is  exhausted;  the  nucleus  >tains  poorlj  ,  the 
cvtoplasn.  in  the  case  of  cells  like  those  of  th^        ney  tubules  may 
be  Sntegrated  an.l  partly  discharged;  or  ther.     ..ay   be  abnormal 
clepoSs  ii  the  meshes  of  the  cytoplasm;  or  the  cytoplasm  may  bec.me 
vacuolated. 

CELL  MULTIPUCATION 

Increase  in  size  of  the  individual  is  brought  about  in  two  ways: 
bv  enlarirement  of  the  individual  cells,  an<l  by  intercalation  of  new 
cells  mr.k  of  increase  in  size  of  the  indivi.lual  as  growth,  whether 
t  arise  fron  one  or  the  other  of  these  processes  but  it  is  necessary  to 
remember  that  cell  multiplication  and  cell  growth  are  not  synonymous 
terms.  Cell  multiplication  is  of  two  main  types-direct,  or  amitotic 
niiH  indirect,  mitotic  or  karyokinetic. 

Diiec U^^^^^  Ainitosis.-This  is  the  rarer  form  o  the  two,  and 
mav  be  said  to  occur  not  at  all  in  the  developnieut  of  the  maramahan 
body,  but  in  fuUv  develope.1  adult  tissues  it  does  occur,  and  is  par- 
tSariv  frequen    in  cells  that  are  multinucleate.     In  leukocytes  and 


CELL  MULTIPLIf^ATIOS 


89 


thU  inethtxi. 


Fio.  10 


B 


totoert  Division;  Mitosis.  - 1"  tf!;;^'^"\he  two  daughter  cells 
„.^^al  I  clividea  ..ith  ejc^;-      \:^^^^^^^^  not  be  necessary  to  have 
It  the  nuclear  material  were  umt'>rm,  ^.^^^^j^j  ^^j-g  ,ts  hall 

':,  borate  '' q^mdrUle,"  but  each  daujhter^^^^^^  ^ 

L  happens  in  hidirect  dw^su)-^^^^^^^^^^^  ^j  ^^^  biophores   so  that 

•,t.,.lf   I  (licates  that  there  is  a  dinerem  .  identical  with  that 

„htamed  by  the  other.    »«= 


JO 


IsmnhfrToHY:  (F.I.I.S  W"  TISSUES 


;.;i..s  .......rntratnl  int..  ra.liatin,  Hl.riU.  f..rn..,.«  a  Mar  -r  aster    an.l 

as  tl..-  tw..  l.alv...  ..f  tl.f  .■rntr..>.m..>  srimrato  an.l  J..ur...y  t..  ..p -m.. 

,„.l,  ..f  tl...  .rll.  a  spindle  ..f  tin.'  fii.rils  i.  s.vm  ''\^'7.»"';/"'.'7-';'';,  'j  '  . 

••   Metaphase.     Ka.l.  <l.r.m...,..n..-  splits  l..nn.t...linall.v  ,.,l..  t  v..  likr 

l.alv,..    tl..-  .la.i«l.t,T  .•l.r.muH..in.-  app.-ari..«  t..  Uvvumv   atta.!..-.!    t.. 

;i'    mantle  fibre,  -f  tl..-  >pi...ll..      TLi;  ^i-li'f"');:  "'  "'»-■  ••It.."...-,...-s 

is  the  tiii..laiii.iital  pr<Mr>-  iii  <«'ll  <livisi..ii.  i    ,      ,• 

Anaphase.     T\l  .la..«l.t.r  .•l.n.n...s..n..s  .Lvr..;,   a    Mu-n.l.er    .1 

.•I.r..m..s..ii..s  .n.w.l  m-ar  tin-  in.tre  of  tlio  aster.  . 

4    TeloDhase'     Tl..-  c.-H  I v  .livi.l.s  i,.to  tw...  tl.t-  l.i.i-  ol  .l.v.s 

pati,l  tS.  tl     c..,nat..r  .-f  tl.o  spi.alle.     Ka.-h  .la,.,l.t.-r  .-.-11  ....w 

ta  M^  I  alf  tl..  .hr..m..s...,u.s.  '  alf  tl..  spi.all..  a...l  ......  .•...tr..s..,ne 

a,         U-r.    Tl..  tw..  last  .nay  p..sist.  ..s  tl..-  attraction  sphere.  ..r  ma 
d   app.ar.      Tl..  .la..Kl.trr   ,.|.r.......s..n.t-s   fns.   n.t..  a   ta>.,l.,   wln.l 

W..l,.u-;  irn^nlarly  sw.U.n  ..r  ,....l..lat..l   a,..l   f..rn,s  tl..-   ...twork  ..t 

the  r.stinn  n.u-l.us. 

ADAPTATION 

Wo  l.av.  alr.a.ly  n.a.le  tl,.  stat.me..t  that  the  ..r«a..isn.^ran  a.h.pt 
its  -  f  to  its  surronn.rn.jis.  a...l  th.  .lo.trin.  ot  th.  s,.rv.val  of  tl..  hlU^t 
"li  -ates  that  wh.r.  th.r.  ar.  n.a..y  i...l.v,.l..als  ..,..l,-r,on.,  H  a  .^e 
ri.e.on.e  l..tt.r  snit..l  t..  th.-ir  ...vin...n..nt.  th.  on.-s  wh-;    .-.t  vvH 
1  e      -      r..,nir.n....ts  an-  th.  ..n.s  who  snrv.v.  a...l  th..r  progeny 
so  n....liti..l    f..r.-.  out  of  .xisc...  th.  f.w.r.  w.ak  proK...y  ..t  those 
W  V.  I  -..lante.l      V  larp-  .U-n.ent  ..f  .hanc.  .nt.rs  n.to  s,.<-l.  a  process 
T^;;    V  Awhile  trl,  is  ..ot  th.  wh.,!.  trnth,    A.h.ptat..,..  .s  n.^ 
.      .  Uve  fortnit..,.s  rn.KliH.ation  of  living'  n.att.r  .n  a  lav..ral,l.  .lir..- 
li';;    In.;  an  activ.  pn.c.ss,  wh.r.l.y  a  .han.c  .,.  s„rron...h„gs  hrn.KS 
nlumt  -i  (-haiiu.  in  ."i.  composition  of  ti.-  hviiifr  matter. 
"      ..m      s'i  aoa.tation   are  ■...m.n.ns;  l.actcria   wl...;l.  or.l.nar.  y 
spli     .,.  .-arl.ohy.lnacs  <-a..  he  n.a.l..  I.y  grown.,  n.  >p.c.al  m.-.  1 
split  up  prot.i,.s;  l>act.ria  wl- vh  can  fernu-..t  one  J''^-  '"V;:;^;  ,^^  1^^ 
m-,v  he  "traine.!"  till  thcv  ferme.it  the  sccon.l  a;..l  not  th.  hrst,  l.a  t.ria 
:S-h  w.^uot  pathogenic  ca,.  he  "'-le  t..  !.ec..na.  s...      1  ..s.- ahm^ 
.w.w.Ts    .r.  due  to  the  ac.i.iirement  ..t  new  (inahtie^  In   tl.t    l.act.ria 
,    i  .g    1       se  V.S  to  their  particular  surroun.lings;  th.  alt.rat.on 
Jan      •  .'r  i      ..  sh..rt  a  tin.,  as  to  n.ak.  it  certai..  that  .t  >s  an  act.ve 
i  c.        T  .e  a(-c,,.ire.l  imn.unity  \n  ...a.,  against  .hseas.  ,s  an  exan.ple 
u  aptati.....  the  cells  a.laptiug  then,sclves  to  ,.>.e  --^If^-^;^^;;^; 
i„  this  instance  the  toxh.  <.f  th.  special  hactcr.um.     Ih  .  mlaptati, 

.,v  remain  f..r  a  long  time  after  th.  t..xin  has  ccas,-.l  t..  he  pr.s.ut 
nia\   reman.  ..•■  ^  alteration  n.  constitution 

l).(-ause  iher.  is  IIIlpr^■^^.e^l  on  t!K  tt  ii    oim   an- 


-,iu. 


l.i-for.-;  /..--I,  in  the  n.i.Mlc  of;  "■■',  huckwunl;  -',■'■■',  afar. 


PLATK   1 


A 


;A 


I 


\'l> 


/V^ 


A 

A 
V 
V 


I 


-^  y 


ii 


Id 


Th 


HI 


Mitiisia. 


CELL  DIFFERENTIATION 


41 


wl.i.l.  =s  ,.assf.l  on  even  W  the  progeny  of  the  cell.    The  capacity  to 
.„l,nt  itself  is  inherent  in  the  molecules  of  the  cell,  an.l  tlie  molecules 
;,,;,'„,,  ..han^-ed  in  response  to  some  aj;ent  or  agency  n.  the  euviron- 
inn.f  it  is  n..t  that  the  tendency  to  vary  -s  mherent,  but  rather  that 
th..  power  to  change  in  a  particular  <^\.  -uo,.  \-  present,  the  change 
iH.in''  in  response  to  the  action  of  a     i-ecific  a-e-ii.     '-.xpressed  more 
,,„urctelv.  a  particular  modification   u;    ,l.e  envir.  r.aent  is  able  to 
.■hange  the  pn.toplasmic  nu.lecule  in    ^   .iTticular    vay.      It  the  cell 
remain  in  the  same  environment   with  .n.  :..-   ■  U.nds  of  food  m(.le- 
,,,U.>  coming  to  it,  the  cell  response  will  be  to  buiUl  up  the  same  side 
..hah.s  within  limits;  in  short,  the  cell  will   not  vary     Hut  as  soon 
.,.  a   new   foodstufl'  is   brought    to   it,  and  dissociated,   an   entirely 
new  ^et  of  ions   mav    be   produced,  and   new  combinations  entered 
int.)    new  side-chains  may  be  built  up,  and  the  protein  molecules  in 
the  cell  itself  therebv  altered.    This  particular  cell  has  gained  a  new 
.•haracter  bv  adaptation,  by  undergoing  a  molecular  re-arrangement; 
.vrowth  goes  on  at  the  same  time,  and  the  new  side-chains  may  be 
detached  into  the  surrounding  medium  or  may  remain  and  be  built  up 
into  the  cvtoplasmic  or  nuclear  molecules.     If  then  a  cell  has  adapted 
Itself,  and"  has  multiplied,  the  process  of  adaptation  is  not  over,  for 
its  progeny  will  partake  in  the  altered  composition  ot  the  molecules 

in  tiie  i)arent  cell.  .  .       i     »     4.1 

V.laptations  such  as  these  will  occur  m  response  not  only  to  the 
fuodstutls.  but  likewise  to  toxins;  and  changes  m  temperature,  vibra- 
tion, light,  and  other  physical  agents,  not  introducing  any  ne%y  ions 
or  molecules  mav  xet  cause  a  re-arrangemeut  of  the  molecules  in  the 
binphore.  and  so  an  actually  altered  composition  of  the  cell,  with 
altered  characters. 

CELL  DIFFERENTIATION 

\  corollarv  to  this  is  that  a  cell  becomes  adapted  to  its  particular 
Mt  of  circumstances,  its  food,  and  so  on,  and  thus  becomes  ditterent 
li„ni  its  neighbor;  this  is  the  reason  that  underlies  cell  diHereutiatioii; 
it  we  begin  with  a  cell,  which  multiplies  itself  into  a  mass  ot  cells,  it  is 
ui.vious  that  the  cells  on  the  outside  of  the  group  are  in  a  relation  to 
the  surrounding  medium  which  differs  from  the  relationship  ol  those 
,1:1  tlie  inside.     I'     >e  begin  with  two  separate  cells,  exactly  similar 
.ach  of  which  gi,     s  into  a  multicellular  organism,  if  each  be  exposed 
t,,  (xactlv  the  same  environment  the  daughter  cells  will  be  ditter- 
,  ntiatcd  in  exactlv  the  same  way.     But  if  the  biophonc  composition 
ol  these  two  cells  is  ditt'erent,  even  if  the  environment  be  the  same, 
•AC  -liall  have  the  daughter  cells  in  the  multicellular  organism  ditier- 
.ntiated  according  to  a  plan  that  differs  from  the  (lifferentiation  of 
the  last  example.     To  state  this  otherwise,  we  would  say  that  eel 
.lithrcnti.  ;ion  is  due  to  two  factors,  bioplioric  constitution  and  physical 
intiu(-ue.,  and  that  in  praclically  every  case,  both  are  at  w-ork      Ac 
rnuid  tluis  understand,  albeit  in  a  hazy  way,  how  the  one  adult  iiidivid- 


42 


INTRODUCTORY:  CELLS  AND  TISSUES 


ual  differs  from  the  other,  even  if  we  were  to  i)resuppose  that  the  ovum 
was  exactly  the  same  in  each  case;  the  more  difficult  task  is  to  determine 
why  one  individual  is  like  another  individual,  why  son  is  like  father,  and 
this  leads  us  to  inquire  wherein  one  o\  uin  is  different  from  another 
ovum.  Two  ova,  side  by  side,  look  to  our  eyes  alike,  let  us  say:  why 
is  one  going  to  become  an  elephant  and  one  an  insect,  and  how  comes 
it  that  the  elephant  is  certain  to  have  a  trunk  and  the  insect  wings? 
Is  there,  in  the  ovum,  a  part  of  the  protoplasm  that  is  definitely  of 
such  composition  that  it  must  form  a  trunk  and  not  a  tail?  And  where 
is  the  protoplasm  hidden  in  one  cell  which  will  determine  that  this 
particular  elephant  will  have  tusks  like  his  grandfather,  a  trunk  like 
that  of  his  great-grandfather,  and  the  temper  of  his  great-grandmother? 
Is  there  a  special  piece  of  protoplasm  in  the  ovum  which  has  directly 
descended  from  each  of  his  thousand  ancestors?  Xo,  there  is  not; 
and  we  can  prove,  from  what  we  know  of  the  protein  molecule  that 
there  is  actually  not  room  for  them.  The  theory  of  "the  continuity 
of  the  germ  plasm,"  as  it  is  called,  which  presupposes  the  descent 
from  generation  to  generation  of  an  infinitesimal  part  of  the  proto- 
plasm of  each,  is  a  physical  impossibility. 

Such  "determinants"  carrying  particular  properties  derived  from 
one  or  other  ancestor,  which  shall  in  due  time  be  distributed  to  one 
or  other  tissue  or  area  of  the  fully-grown  individual  and  shall  endow 
that  particular  tissue  or  area  with  the  properties  seen  in  one  or  other 
ancestor  demands,  it  will  be  seen,  that  every  separate  feature  in  the 
body,  even  down  to  the  particular  markings  of  the  thumb  prints 
(which  are  alike  in  no  two  individuals),  shall  be  present  in  the  fertilized 
ovum,  demands,  in  short,  that  not  merely  the  microscopic  nucleus 
of  that  ovum,  hut  the  chromatin  or  whatever  part  of  it  conveys  the 
hereditary  characters,  shall  be  made  up  of  these  innumerable  determi- 
nants. Now,  according  to  Weismann,  these  determinants  cannot  be 
simple  molecules  of  matter,  but  must  be  molecular  groups,  and  as  we 
have  pointed  out  that  living  matter  is  proteidogenous,  each  individual 
molecule  must  be  of  a  size  which,  according  to  physicists,  is  almost 
visible  by  the  ultra-microscope  Regarded  thus,  it  is  a  physical  impos- 
sibility that  the  minute  nucleus  of  the  impregnated  ovum  can  contain 
all  the  determinants  demanded  by  this  theory.  If,  therefore,  we  can- 
not accept  the  idea  of  determin.rts,  is  there  any  other  means  by  which 
we  can  visualize  the  facts  of  inheritance  and  of  individual  variation? 
This  biophoric  hyjjothesis  apjiears  to  us  to  afford  the  only  means  of 
explanation  at  present  possible.  The  elepliant  ovum  develops  into 
an  elephant  and  not  into  an  insect  because  the  elephant  ovum  is  made 
up,  in  the  main,  of  molecules  of  a  certain  average  composition,  a  ring 
made  up,  let  us  say,  of  small'T  rings  each  represented  by  A: 
A  A 


a-   / 
A 

\ 


A 
/ 
A— A— a 


/     \ 
A  A 

\        / 
I— A— A 


CKLL  DIFFERENTIATION 


43 


A  l)ir«l  ovum,  on 


the  otl^  r  hand,  may  be  made  up  of  X  rings,  thus: 


X 

/    \ 
X       X 

I      I 

X       X 

/ 
A 


The  biophoric-  molecules  of  an  insect  ovum  might  be  represented  by 


U 

/\ 
U— R 


These  may  thus  differ  one  from  another  not  only  in  general  com- 
position (as  A  is  different  from  R  or  X).  but  also  m  number,  and 
mode  of  apposition.  The  fundamental  grouping  of  the  molecule  of  all 
eU'pliants  is  the  same,  thus: 


A      A 

\/ 
A 


the  biophoric  molecules  of  the  ovum  of  one  elephant  differ  from  those 
„f  another  in  certain  slight  modifications  of  one  or  more  of  the  constit- 
uent parts  of  the  ring,  which  may  be  represented  as  side-chains;  thus 
for  one  elephant: 


a-A 


A- 

/ 


for  another  elephant: 


A— a 


A; 

as  no  two  individual  elephants  are  identical  or  can  be  represented  by 
the  same  formula,  it  is  evident  that  progeny  of  any  two  will  present  a 
ni.Klification  of  the  formula  seen  in  either  parent;  these  modifacations 
arising  by  elimination,  interaction,  or  summation  of  the  characters  rep- 
resented as  side-chains.  , 

Having  thus  dealt  with  inheritance  and  the  effects  of  fusion  of  the 
male  and  female  elements  in  the  new  individual,  let  us  now  consider 
the  modifications  acquired  by  environment.  ,  ..      •  j- 

Acquired  Modification.— Passing  on  to  the  evolution  of  the  indi- 
vidual from  the  ovum  and  the  differentiation  of  his  various  tissues  and 
..rgans.  it  must  be  clearl>-  realized  that  when  the  ovum  divides  ii.to  two, 
each  daughter  cell  has  conveyed  to  it  biophoric  molecules,  and  that  so 
these  biophoric  molecules  while  coincidently  multiplying  by  the  successive 


■ISSWS\li' 


44 


ixruoDnroHY:  ( i:i.i.s  wo  rissrKs 


.on  UKi  .nMlt.p!  cat„.n  ol  t  h,.  .rlls  „(  tl.o  «nmin^  i.ulivi.lnal  c.n.e  to 
iK-.l.stn l.ntcl  to  a.   the  fs.nos  ,.f  th.  l.o.ly.     So  far  as  w.  <,„.  scv  ti.ev 

I.nss  to  tl.f  gmn  (vlls  „,  an  iiM,.l,a,.K.-.l  «■ liti.m,  l.„t  i„  tlu'  s,.,ressi„„ 

ot  .I.V.S.O,,.  wl.K-l.  K.v  ns(.  to  tiM.  snn.ati.-  or  l.n.ly  ,rlls,  tlu-  infln.-n.rs 
'.'Tit'  ^•"•'.■^■^^'^•- «^->"-n'tio.,s  of  ,.dls  an.  ,-xpns,-.l  in  th.  .linVrent 
part.  n(  tiR.  Kn.win^r  ,.,„|,rv„  ,),|iVr  vrrv  greatly.     It  is  i\uv  to  the  .liJlVr- 
once  ...  position  ,.li,s  tl„.   ,iiffm-nce  in   foo.|stntrs  a-ul    phvsical    an.l 
.  ......<..l  aKo.„.u.s  to  whi..I.  tl...  crlis  arc-  ...vposci.  tl.at  the  containe.l 

l.iol.horr.   ,ei-on.o  ino.liho.l,  until  ovontnally,  the  n.o.lifi.-atio..  heeo.nes 
so  gn-M  that  ...stea.!  of  these  l.iophores  l.eii.g  able  to  repro.h.ee  the 
whole  ....livKliial.  they  now  l.eeonie  eapal.le  of  .ontrolling  the  formation 

ot  only  o.ie  part.ei.iar  d.lhre.itiated  order  of  ceil 

Following  ,ip„n  this,  the  general  staten.e.it  inav  he  made  that  the 
more  ,,mu„m,rd  fhe  (liffnentuition  of  a  cell,  tlir  'irs.s-  n.  cnmntij  for 
rcproduchon.  ^  et  there  are  certain  cells  tl.at  are  specialized  aii.l  cin 
yet  reprodnce;  l.r,t  they  nprodnce  only  their  ou„  .lilferei.tiate.l  and 
n.odihed  kind,  gland  c.ll  reproducing  gland  ee.I,  nmsc-le  cell,  nmsele- 
and  even  this  in,iltipl.cati..n  can  occur  only  aftei  th,  ditferctiated  cell 
has  und.tJerei.t.ated  itself  again,  that  is.  has  reverted  to  a  simpler 
less  diflerentiat.-d  stage.  The  cell  that  has  lurome  differctiated  that 
IS  loses  the  characters  it  has  acqnired,  an.l  I.ecom.'s  a  "vegetative" 
eell  ...  ton,,,  an.  lyet  when  this  cell  reproduces,  its  progenv  assn.ne 
onee  more  the  d.Herentiated  type  eharaeteristic  of  the  adult  cell. 


FERTILIZATION 

We  shall  take  ..p  very  I.riefly  some  of  the  fi;'ts  .•oneerne.l  with  fertili- 
zatio..;  that  .t  has  n„t  hitherto  entered  i.ito  this  text,  is  d,.e  to  the 
tac^t  that  growth,  a.laptat.on.  and  cell  ditferentiation  can  proceed  with- 
out It;  study  ot  the  h.wer  invert.-l,rate  forms  indicates  that  it  is  in 
them  a  means  ot  rejuvenation  of  the  l.ioplw.re,  l.ut  tl.at  it  is  not' an 
essent.al  to  the  c....tn.ua..<e  of  the  species  through  consi.leral.le  ...iml.ers 
o  generations.  In  its  s.mplest  phase,  conjugatio..  is  the  direct  union 
ot  wo  hke  m.hvid.ials;  hut  even  low  down  i.i  the  scale  we  I.egin  to 
hn.  a  (1.1  ere.it.at.on  hctween  the  male  a„<l  the  female  gern,  cell-  the 
male  tends  to  show  .tself  n.otile,  invasive,  while  the  fc-male  ten.is  to 
..'  pass.ve,  chiefly  l.ecaiise  th,-  cell  is  loaded  with  the  volk  necessarv 
lor  the  support  ot  the  new  i.ulividual  after  fertilization:  Of  this  food 
niatenal  th.-  male  element  or  si,ennatozoo„  shows  little;  it  consists 
ot  a  micleus  a  centrosome.  and  a  small  amount  of  cviuphism  which 
api,ears  ehiedy  as  the  flagellar  tail;  the  male  eell  is,  in  fact,  of  a  dis- 
I.roportionate  sniallness.  '  "^ 

From  a  very  early  .late  in  the  devel.,pment  of  the  in.iiviuual  .,v,im 
the  germ  cells  l>e.-oii,e  marke.i  .)ti'  from  the  somatic  or  !..-.dv  cells'  the 
germ  cells  rema.ii  rich  in  chromatin,  none  of  « lii.l,  is  east  .,,'it 

1  he  ..hservat.ons  of  Box  eri  and  others  indicate  tl.at  the  cells  .lestine.l 


FERTIUZ.VnoS 


45 


i,,,  risf  t..  the  tissur.  in  Kfi.fral  inukTKo  a  pnHr-  ..I  rf.luotu.M 

:,,  ;|,,ir  H.n.uiatin;  very   i...>sil,lv   tl.is  pr.Mr^s  uf  n;.lnftu.M   rcn.lors 
,,„,„  i,„,M,ahk-  ..f  Leing  totipotential,  >.  v.,  <>t  giving  ri;.-  t..  the  ^^\u^c 
i,„|ivi,h.al,   leaving  then,  earal.ie  -nlv  <.f  giving  ..ngm  to  u  speeihe 
,■,.,,!,•  or  tissues  accnling  to  their  environniei.t      Nor  does  it  seein 
,lnt  the  eventual  sexual  cells  are  of  necessity  al.solutely  i.lentical  in 
,1,,  ,„,,„i.it  of  chromatin  which  tliey  contain;  a  stu. ly  ot  the  sperma- 
„„„•,    c>peciallv  of  insects,  an.l  of  the  pollen  ..t  plants,  has  shown 
nrciiilv  tliat  in  any  particular  instance  their  spermatozoa  may   he 
MiKiraUMl  int..  two  appn.ximately  e.i.ial  groups,  ot  which  the  nieml.ers 
,,,  ,,„i.  .rroup  contain  either  one  chromosome  iii  excess  i.t  the  numl.er 
,„„tMine,l  l.v  memhers  of  the  other  gn.up.  or  one  chromosome  (acces- 
sory chromosome)  markedly  larger  than  the  correspoiuling  chromosome 
n,  ,l,at   other  u-roup.     No  such  .litlerence  is  ol.serve.l  in  eonnec  ion 
w'ltii  the  ova,  an.l  as  tliese  species  atlor.l  approximately  e.iual  numbers 


V 


V    ^       v^         '^^         Sf' 

5i*L!_L*lll:Ll 


■,]U. 


Difffrenliated  tomatic  (i'mcs  of  aduU. 


Srhnn.a  of  Kcrm  an.l  somatic  ell  .liflercn.ia.ion.     (After  Klcl.s.) 


„,  ,„alc  an.l  female  pnigeny  an.l  no  other  functional  .litlerence    ai    Ik 
,l,,..,t...l  or  imagine.1  hetween  the  two  gr..ups  ..t  spermat..z..a,  it  i 
HM.    .1  that  the  ..ne  gn.up  (that  with  the  accessory  chromosome) 
l";^e"  Uilale.  the  otlu-r  n.ale  attributes.    This  conclusion  is  n..w 

1 .Miiing  generally  accepte.1  l.y  l.iohigists.         .      ,       ,  ,.       ..  ^.  .. 

We  l.ne  state,  that  there  is  lu.  re.luc-ti..ii  m  the  chromatin  of  the 
.,  IWcntiatcl  germ  cells;  l.i.t  we  have  n..w  t..  a.1.1  to  tl;-  «  a  -nent 
,!.,t  tl,.-  .enerati..n  of  germ  cells  imme.l.ately  prece. Inig  tl  e  ^  "a^^^^^^^ 
,.,  tiie  ..va  and  s,.ermat..z..a  dor.  uii.lerg..  a  re.luctu.n  ..t  ^It"'"- t 
,M,ring  the  pn.cess  ..f  maturation,  so  that  the  mature  spennat..zo.,n  or 
;„, tains  just  ..ne-half  he  numher  .,f  clir..m..s,.mes  charac  ens  ic 
„,  the  spe.-i.-s  (aiul  it  will  he  recalle.l  that  this  is  a  fixed  numher  f..r 

'"!,',Thrmaturati..n  ..f  the  spermat..zo.iii.  we  may  st..      oriefly  the 
ht  that  a  pairot  spcrmat..zoa 


\i\ry  11 


1  turn  comes  from  a  primary  .-[v 


>rmatocvte,  this  fn.m  a  spermat.tgo- 


^evmt^fmm  -f^mrii-^^jiBRT  wm 


46 


ISTRODVCTORY:  CHU.S  AM)  Tlf^SVES 


iiiiiin,  and  this  from  a  primordial  Kcrm  cell,  and  l.y  the  time  the  sper- 
matoziuiii  is  formed  it  has  oiie-lialf  the  normal  immher  of  chromosomes. 
The  four  cells  derived  from  the  primary  spermatocyte  all  become 
spermatozoa,  whereas,  in  the  ease  of  the  ovum,  tlie  primary  ooc\  te 
gives  rise  also  to  four  cells  hut  only  one  of  them  becomes  a  functional 
ovum;  the  other  three  are  defiencrate.  and  are  cast  out  of  the  cell  as 
polar  bodies,  and  this  casting  out  does  not  occur  till  the  spermatozoon 
has  entered  the  ovum.  This  intracellular  occurrence  is  for  the  purpose 
of  reducing  the  chromosomes  of  the  ovum,  so  that  the  ovum  proper 
is  the  only  one  of  the  four  which  remains,  aiul  it  functionates  with  its 
"hromosoines  reduced  to  one-half  of  the  number  present  in  the  cells 
of  the  adult  individual.  The  steps  of  the  process  of  maturation  of 
the  spermatozoiin  and  of  the  ovum  we  have  omitted,  but  these 
intricate  "nuclear  dances"  are  evidently  a  means  of  ensuring  that  the 
chromatin  of  the  original  germ  cell  shall  be  impartially  divided  among 
all  the  (laughter  cells— the  spermatozoa  or  ova;  and  the  reduction  of  the 
chromosomes  brings  it  about  that  the  fertilized  cell,  summing  the  two 
sets  of  chromosomes,  each  reduced  by  a  half,  shall  begin  life  with 
exactly  the  normal  number  of  chromosomes,  and  these  contributed 
etpiallv  bv  the  two  parents.  The  cytoplasm  of  the  new  inflivldual  is 
supplied  liiainlv  from  the  mother,  but  with  the  chromosomes  (supplied 
thus  with  striking  equality  from  both  parents)  must  come  the  rnost 
important  of  all  those  factors  which  we  are  accustomed  to  consider 
in  the  problem  of  heredity. 


INHERITANCE 

Heredity  is  the  conveyii  .  e  to  the  ofi'spring  of  the  i)roperties  of  the 
parents  and  of  the  parental  stock,  so  that  the  child  inherits  familial, 
racial,  and  specific  characters.  Hut  this  docs  not  (L^scribe  the  child, 
because  interwoven  with  heredity  is  variation,  and  this  of  several  orders. 
(1)  There  is  the  variation  that  comes  from  one's  course  of  life,  as  is 
seen  in  the  type  that  is  recognized  as  the  sailor,  the  farmer,  or  the 
undertaker;  variations  so  acquired  are  known  as  modifications  and 
can  be  divided  into  those  acquired  in  intra-uterine  and  in  postnatal 
life.  (2)  There  are  variations  that  arise  because  the  individual  is  the 
result  of  amphimixis,  i.  c,  the  fusion  of  the  gerini)lasm  of  two  individuals 
who  differ  op.e  from  the  other.  The  chihl  cannot,  on  this  account, 
be  an  exa<'t  copy  of  cither  parent,  but  must  show  variation  from  each. 
(3)  The  molecules  of  gcrmplasm  of  iwo  parents  are  so  coini)licated  that 
their  interaction  never  i)roduces  the  same  result  twice;  even  the 
thousands  of  fish  from  the  same  si)awning  differ  from  one  another. 
Finallv,  we  must  admit,  that  the  biophores  of  the  parent  which  supply 
the  cerm  cells  are  prone  to  variation  during  the  individual  life  of  the 

parent. 

The  importance  of  the  problem  of  heredity  in  disease  is  great,  and 
we  make  no  apology  for  insisting  on  its  consideration. 


INUKRITASCE 


47 


I 


'""■  ''"'^r,,  s  r;nd'.  ti\hl;;  <iis.n.«ui*  w-  - "  i""- 

„r  iS  .v>m<'  i)r(.iHrties,  MRU  aistinctions. 

,,,„„  from  an  ape,  a.ul  ^^-7.;^,^  f- '^"•^^  J^  „f  fixitv  in  these  characters. 
\\V  see  that  there  is  an  ««'<;'  '""^;*Vr..to,-harcters  are  more  firmly 
Z  that.  .leahn«  .ith  man.  h.s  ^^^^^l^^^^^,n\^.  human, 

,,as  possesse.!  longest  he  ^'^es  up  east  r^a  n_  •  ^^.^^  ,,e,yone  is 

Racial  Characters.-To  go  n<.  ^•'     "^  ^j^^,,^.  ^^^^  eolor  of  tlie  skm 

,„.,i,iar  .ith  racial  <  'tt^"^?''^,!^',,^  ,'    ft/n^ore  strictly  pathologieal 
,,...  shape  of  the  skv,l^^a,u    the  s^^^^^^^^^  ^^^^^^.^.^  ^^^^.^^  ,,  ,„, 

,l..l.ls.  one  may    recall   t Ic       tte  enc  ^^^^.^^  ^^^^^^^^^  ^^^^^, 

„.i,,,,,ie  cl>seases;  thus  the^Ja^^^^^^^^^^^^  ^^^^^  ^^^^^^^.  ^„^  ,.,,3  of 

are   less  susceptible   to   *  »^"f  r^'  .i^t^tl  with  anthrax;  negroes  and 
Alu'crian  sheep  can  scarcely  he  i""^"  atca  ^    -,     ^^^d  so  on. 

A,nerican  In.lians  are  h>gh  >"  --^*  Jj  J;;l,,  knowledge  that 
1„  ,H,n-microlnc  "diseases,  it  is  am  ui  functicnal  nervous 

,,„.  Ih-hrew  is  prone  to  d.ahetes    the  ^^en  J'^    ^^j^^^^j^.,,  „f  ,,i,es- 
ai..a>es;  the  luiglish,  t..  gout,  an    t  e  Ame^^^^^  ^^^^^^^  ^^^  ,jf^.  . 

I  ,he  outcome  of  T'^^t*-"'^;  ^^'^^l^he  niemhers  of  a  family  tend  to 

FamiUal  Characters.     Not  _.n     ^^"^^^  distinctive  traits  that  are 

HMnihle  one  another,  but  there  are  urtau  .         j  ^^.^^,,^6,   a 

f  -Hi   in   many   successive   ^!^Z.lr^^^onr  said  Falstaff. 
I,,,,.,  of  some  special  part^     that  thou        ^^^^^  ^^j^g^    ....    a 

1  have  partly  thy  mothers  won.  '  _  '  ^^jj  condition  such  as 
,„,i,l,  hanging  of  thy  ^f^'^'^lr^^.'^^^l^^^^ 
.Ihuiism  (deficiency  "V""'""rt'  f^re  (.It  of  insignificant  injury). 
,,.ility  to  excessive  I'eni""*^,^  t  ,.sess  on  of  an  extra  .ligit.  When 
r  a.tu.  1  malformation  such  as  tin  P"'^^^^;^""  ,  y^^^  _  traced  in  a 
.,e  consi.ler  that  such  peculiarities  -  ^^^  ^^  ^ctio^^  of  new  blood,  it 
n.ilv  for  centuries,  ^'espite  the  c,.nstant  mtn^^^^^^^^^^^^  germplasm 

.-,  iii.nt  that  these  are  do°^>^*  I'"^'  ^^^^rHomc  of  thc<^c  characters 
iSS^uS  tS:  r^:  o;  Ihem  which  appear  in  one  sex 


4S 


iSTiionnroiiY:  cells  .\si>  t/ssi'ls 


ami  arc  traiisiiiittrd  l>y  tlic  otlicr.  Hcriiiipliilia,  lor  t'xaiii]>U',  rarely 
apjH'ars  in  tlu-  t'ciiialcs  of  an  aircctt'd  family.  l)iit  frc'iiiciitiy  in  their 
sons.  (  liaraeteristies  may  ski|)  a  p-neration  or  more,  so  that  the  appear- 
ance of  sneh  in  eliildren  \vho>e  i)ari'nt>  were  free  from  l)nt  whose  grand- 
parents or  pre<'edin^'  foreliears  were  atfeeted  l>y  them,  is  desijjnated 
atavism. 

Parental  and  Individual  Characters.  The  charaeters  that  descend 
from  the  i)arents  to  an  individual  may  lie  blended,  that  is.  he  m.iy  possess 
a  n-.ixture  of  the  paternal  and  maternal  features,  intermediate  between 
tiie  two,  or  they  may  he  particulate,  that  is,  lie  may  resemhic  one  and 
not  the  other.  Tiu-re  are  certain  parental  charaeters  that  ordinarily 
cannot  hiend,  and  sex  is  the  most  striking  of  these.  Less  important 
is  such  a  character  as  the  color  of  tiic  eyes;  one  parent  may  Inne  l)lne 
and  one  hrown  eyes;  the  children  fienerally  do  not  show  an  inter- 
mediate color,  lint  either  Mne  or  hrown  eyes.  One  of  ♦he  two  parents, 
in  properties  that  are  nnliUe  or  antagonistic,  is  apt  to  he  dominant, 
and  the  other  is  then  recessive. 

Mendel's  Law.  VVithont  piinj;  deeply  into  the  particulars  of 
inheritance  in  the  matter  of  antaijonistie  charaeters,  wt  ^.lall  indicate 
the  exactness  with  which  nature  works,  as  it  was  ohserved  hy  the 
Austrian  monk  Mendel,  whose  work  has  in  this  century  heeii  revived. 
Let  us  take  for  exami)le,  as  he  did,  the  flowers  of  the  pea;  some  strains 
ha\c  white  flowers,  others  colored.  Color  is  a  p<)siti\('  accpiirement, 
and  whiteness  means  latency  or  loss  of  this  acquirement.  If  now- 
red  and  white  flowers  are  crossed  upon  one  another,  the  hyhrids  which 
result  follow  a  law  in  regard  to  manifesting  this  particular  character 
and  the  first  fxeneratioii  is  red.  The  red  color  is  (lominant,  and  there 
is  no  indication  of  the  white  color — the  white  heinji  recessive.  Hut 
in  this  experiment  the  white  color  is  only  latent,  and  this  fact  will 
appear  if  this  first  generation  (red)  he  allowed  to  fertilize  it^^lf;  among 
its  progenx'  one-(|uarter  of  the  individuals  will  he  white,  that  is,  will 
show  the  recessive  quality.  If  this  white  individual  he  self-fertilized 
again,  all  its  ])rogen\'  will  he  white.  Xow  of  this  second  generation 
of  four  ])lants  (three  red  and  one  white),  of  the  three  red,  one  will  give 
only  red  jirogeny.  the  other  two  of  this  second  generation  will  have 
the  characters  of  the  first  generation  of  hyhrids,  that  is,  they  will 
give  rise  in  the  next  generation  to  one  dominant,  one  recessi\e,  and 
two  hyhrids  that  again  will  produce  this  same  percentage  of  dominants, 
hyhrids,  and  recessi\t's.    This  will  he  understood  hetter  from  Fig.  12. 

The  formula  may  he  set  down  as  follows:  if  1)  represent  :i  plant  with 
the  dominant  red  and  its  gcrmplasni  and  K  one  witli  the  recessive  white 
and  its  gennplasm.  then  the  first  generation  of  crosses  of  1)  and  H  will 
all  he  DR.  and  if  these  DU  individuals  he  crossed  the  result  will  he 
.r(I)I{  +  DU)  =  .r(I)I)-f  2I)1{  +  HH),  or  in  other  words,  a  dominant 
crossed  with  a  recessi\-e  gives  in  the  second  generation,  as  regards 
this  one  particular  feature,  one  dominant,  two  hyhrids.  and  one  reces- 
si\e,  and  of  tliesc,  each  dominant    uii!  gi\c  nothing  hut  dominants, 


MEXDKL'S  LAW 


49 


,,,1,  r..r>>ixf  notWm  »><'t  recessive.,  an.l  eneh  hybrid  the  same  pn,- 
,„,rtinii  of  dominant,  hybrid,  mid  recessive. 


Fill    12 


l\pih>iijf<a 


r.ii'iiiiiiiii 


U  im  AIM  •• 

.  1,1  ii  iliiTiiiuant  property. 


fi 


ID 
IR 


rz   RC 


3     [ IR  I     PR 


ID 

la 


ffa/M    IRR 
IR 


2DR 


IDD 


3D 


,f  M..r.ders  law  for  a  single  pair  of  ••an.agoru^tic"  properties:    A.  the  resuU,  „,  hybridi- 
zation of  a  pure  dominant. (/»  with  a  pure  recessive  (K)  forn,.     (Batesou.) 

The  essential  point  to  he  graspetl  liere  is  that  while  oi.e  property 

.nii.ates,  the  other  is  only  latent,  and  may  show  itself  "'t»ie  absence 

I  he  tiomiiiant  property  or  miiigle.l  with  it  .n  a  blend.      1  h^'  la^^ ,  too 

-  not  hold  in  the  crossing  of  distinct  species,  and  we  quote  it  only 

4 


ys-  -.  -I 


50 


iSTiionnroiiY:  cf.i.i.s  .\\i>  tissiks 


to  indiciiti'  liDW  ii(<iiriitc  n  Imsis  cmii  witli  onr  iiiiprrfict  kin»\vlrtl;rc  we 
liiixc  for  the  ('(iiisidcnition  of  i>rtil>lcins  of  licrnlitv  in  tlic  liiiinaii  s|)C(ii's. 

Atavism.  Tlii>  i>  thr  iipiMiii-jiiKc  in  a  pvcn  K('>>*'>'iit><»>  <>'  traits 
not  itrcsint  in  tlic  parent  lint  cliaractfristic  of  ••arlitr  m'ticratioiis, 
anil  is  ^vv\]  to  lie  in  aci'onlancc  with  Mcndi-rs  law.  If,  liowcxcr,  we 
find  traits  appear  which  are  cliaracti'ristic  of  an  earlier  state  in  the 
pli\lo>;eny  of  the  species,  wc  designate  this  reversion.  In  reversionary 
inheritance  or  reversion  wc  have  always  a  return  to  a  lower  typo 
a  development  not  conip!  'tely  np  to  the  ])resent  type  hut  attainiin;  a 
stage  eliaraeteristic  of  an  earlier  period  in  the  development  of  the 
species.  An  example  of  snch  is  the  a|)pearance  of  a  niicrocei)halic 
child  or  of  a  chilil  with  indications  of  ])ersisteiit  );ill  clefts;  not  all  such 
cases  are  true  reversion,  for  some  may  he  merely  examples  of  intra- 
uterine disturliance.  .\  jierfeit  exaiuple  of  reversion  is  found  in  Darw  in's 
experiments  and  those  of  others,  in  which  when  widely  ditferinj;  breeds 
of  pigeons  were  crossed,  the  progeny,  disrcfiardiii^:,  as  it  were,  all  the 
recent  ac(|uirements,  have  a|)iieared  exactly  similar  to  the  form  of 
wild  ])ij;eon  from  which  all  the  different  varieties  took  their  origin. 
One  seems  to  see.  froiu  time  to  time,  the  ofi's|)rin>;  of  parents  of  widely 
diverse  stocks  sliowinj;  this  reversion  to  a  lower  type. 

Familial  Degeneration. — This  is  a  form  of  d«'t;enerati()n  which  we 
ascril)e  not  to  the  interaction  oi'  two  antaj;onistic  >;erm]ilasms,  hut 
to  a  defect  in  one  or  hoth  i;.  t-d  hy  toxic  intinences,  which  modify 
the  constitution  of  the  piirc  jrerm  cells.  The  class  so  produced 
we  desij;nate  degenerates  the  prodtict  of  those  leading;  vicious  lives. 
The  de>:enerate  is  of  ])oor  hodily  development,  the  hrain  is  smaller 
than  normal,  its  convolutions  less  marked,  there  is  little  cai)acity  for 
prolonged  tiionjiht,  and  a  lack  of  moral  sense  in  all  these  j)oints,  then- 
is  a  res'-mlilance  to  a  lower,  less-developed  race  of  otir  sjjecies.  .Such  art- 
apt,  in  turn,  to  jiroduce  children  who  are  idiots,  stillborn,  or  monstrous. 

Spontaneous  Variation;  Mutation.  We  have  previously  lueii  deal- 
ing with  ronditions  a])])earin};  in  the  ancestor,  ami  conveyed  to  the 
oti'sprinji;  hut  there  a])pear  in  the  offsjjrinjj  conditions  and  relationships 
tliat  are  new  to  the  stock,  that  have  «r/,vrv,  and  these  are  called  sponta- 
neous variations.  Tiie  clover  has  a  tri-partite  leaf,  Imt  a  four-leaved 
clover  is  ( ccasionally  found,  and  does  not  luean  that  the  ancestors 
of  the  clover  plant  had  a  cnuidri-partite  leaf.  Wc  describe  this  as  a 
spontaneous  variation.  We  find  the  same  thinj;  occurring;  in  the  human 
species;  su])erniuuerary  luaiumie,  fingers,  or  vertebne  occur,  and, 
once  present,  tend  to  be  inherited.  The  first  of  these  in  any  series 
to  happen,  was  a  mutation,  a  spontaneous  variation;  and  botanists 
have  been  alile  to  show  that  a  new  variety  will  suddenly  arise,  and 
self-fertili/ed,  remain  true  to  its  new  ty])e.  .'^ome  say  that  evolution 
works  ill  this  discontinuous  way,  and  that  a  new  variety  or  i.;'w  sjiecies 
does  not  come  by  slow  gradation,  but  by  sudden  genesis.  It  luay  be, 
of  eour'^e,  that  we  have  here  an  exami)le  of  cumulative  inheritance; 
that  is,  w  here  a  blend  ili^tead  uf  rvhowiiig  a  feature  intt^^fiediale  Ijctween 


FORMS  OF  ISIIKRITASCE 


51 


„,.,  .litr.ri..K  i.i.nM.tal  featur.-s.  slmvvs  tins  t...tnn-  .xanKerattHl  in  the 
.       '  ..f    l'..t  far  hoyo.ul  that  t.atnrc  i.,  ...u    ,.an-nt;  hut  wj-  have 
L  tn  r.na.Mlur  that  .nutations  hav.-  h«vn  ..htauMMl  hy  various  phv  s.cal 
',t\V,ts  ,■  '/    th.-i-fhini.r..fchi-min.lan«'ntsac'tnijr  upon  ova. 

The  Theory  of  Inheritonce.  ThtMonsi.ltTationof  f.rtih/.at.on  an.l  the 
„r.,.r~M  >  that  ,.r..r.l»-  it  lea.ls  us  to  suppo  ..•  that  oach  parent  c.ntr.l)- 

.'  .Hu-half  to  tlu-  ,t-rn,  <rll  of  the  offspring:  .  If  the  .•hrun.oso.i.es 
..n-  of  i.it.rnal  half  of  niaternal  orinin,  and  the  heritable  material  is 
;.vi.lentlv  in  these  .hro.nosoines  and  any  the..ry  of  inheritanee  must 
.l,...l  with  the  chn.mosomes  and  their  c-onstituents  -that  is.  witii  the 
l,i„pl,„ri,,  luoleeules  .•..nveyed  in  the  chromosomes. 

\Vr  may  >;ro.,p  tlu-  various  forms  of  mheritanrc,  most  of  vshuli 
|i:,\ !■  hccM  refemd  to,  as  follows: 

(   I)  rre>entin>;itsrlf  alsoin  theoffspriii);:  ,.      i    .  j- 

1.  Dominant,  wholly  replaeinntheeorrespoiKhnglnitdivercent 

feature  seen  in  the  other  parent. 
•>    Blen.led,  this  particular  feature  in  the  oiVspring  hein>;  inter- 
mediate in  character  iietween  that  exhibited  in  the  two 

:i.  Ill' mosaic  form,  in  certain  cells  the  ,,aternal,  in  others  the 

maternal  feature  heiuK  dominant. 
4.  IMeiided  and  excessive,  the  feature  heiUK  more  pronounced 
tliiin  in  either  parent. 
I /,'i  riirecognizahle  in  ihcotVspriiiK:  ,    •      , 

1  IJccossivc.  and  replaced  hy  ((.rrespondinp  feature  deriveci 
from  the  other  parent,  hut  as  such  latent,  capable  of 
rcapjieariiiK  in  hiter  generations.  _ 

•1.  .\hsent,  wholly    wanting   in   siibsecpient    generations,  the 
absence  being  due  either: 
(„)  To  casting  out  of  an  inherited  condition,  or 
xh)  To  the  feature  seen  in  the  parent  being  an  acquire- 
ment and  not  an  inheritance. 
Or   on  the  other  hand,  considering  the  individual,  we  note  that  as 
r.-ards  anv  particular  feature  or  group  of  features,  there  may  be: 
"  1^    S,',rwiO  Inlwritfinrr:    The  offspring  not  being  in  this  respect 
advanced   beyond  either  parent,  but  at  the  same  time  not 

fallen  behind.  .  , 

.  /,',   I'mnrrsmf  InheriUuice:    The  offspring  l)eing  advanced  beyond 

themoreadvancedofthetwoparentsandexhibitingeither: 

1.  Excessive   development   ot    the   condition   or   conditions 

alreadv  observable  in  one  or  both  parents,  or 
•1.  Spontaneous  variati:)n  (mutation),  i.  e.,  the  appeorance  of 
conditions  not  i)reviously  iiote<l  in  either  parent  or  either 
parental  stock. 
lYj    Rdroijresdee  or  Reterslomiry  Inhentancc:  The  offspring  revert- 
ing as  regards  any  feature  or  group  of  features  to  a  low.-r 
,iage  in  the  phylogcny  of  the  species. 
( /))  yuh-inheritancc:    Apparent  or  actual. 


52 


isruDDii  riutV:  <  i:i.i.s  \\i>  rissi  rs 


It  will  !»«•  still  tliiit  (|iiiilitir-  iKiiMvi'tl  l>v  (lie  itiirtiital  liii)|ili(irrs 
may  Ik-  retaiiitti  «\eii  if  in  ii  rtiTssivf,  latt-nt  lomlitioii.  Tin-  fact  that 
tlu'  Mt'iidrlijiii  li\liriil  att»T  a  iiuiiiIkt  of  ^joiicraticnis  ran  pnKlncf  a 
pnrt'Iy  iloininaiit  or  imrcly  rrcc^^ivc  imlisidiial  sIh>\\>>  this,  aral  con- 
jiiHatiun  caiiiiot,  tlunfurr,  l>f  a  ilniiiital  nniori  nf  two  l)io])lu)rt'S 
with  a  n-snltiiij;  \w\\  liioiilioric  siil>-.tanit'.  Nor  can  there  lie  sojiarato 
Kiophorcs  repriMiitinj;  ca(  li  iiiili\iilnal  ance>tor.    Tlu'  following  is  our 


ySfM  MOTHt/f  CLLL  KtfrBffiO). 

^ini,i,  n^e i(  four 

if)trif>utoioa. 


F.I,.   II 

COCynS  iHrBHID), 

iivir.t,'  ri.tt  each  tci'ne  Cviim,fy nducticit. 


S',  /. 


1  a*'"^  \  (i^   (^■■^ 


■Sj,£ 


Dnminar.:. 
DD 


<••>       1 


DR 


I 


Jh  brill. 


D!i 


Scliema  to  illuBirtitc  .Mt.n.l.l's  liiw  rfiiarding  the  wcnmi  liyhn.l  Ki-nrrrition  to  illustrate  the  pffecu 
of  reduilinn  i.f  the  chriiiTiii».iirii'»  in  otiiieDcsi*  an.l  .'■permatourncMs  K.icli  germ  cell  (Brst  rowi  is 
originully  provided  with  rl.roiii„9oi],i-3  <it  palurniil  (black)  and  of  niatcrnui  '.riuin  (white)  The 
existence  ,.f  the  liiw  demands  that  in  (he  process  nl  rudiictinn  the  ■.viini  and  the  sperniatoioOn  (nceond 
row)  becnme  pmvided  with  chroniowimea  (and  hic.phores)  thai  are  of  either  piiiernul  or  of  nialernRl 
ilescent.  hut  not  of  JmiiI,,  allhr>ui!h.  as  ahnvc  noted,  the  hiophores  may  in  their  Rrowth  and  develop- 
ment have  attracted  side-chains  formed  primarily  by  the  .)pp..sed  ..rder  of  biophorcs,  to  tlte  exclusion 
of  those  originally  belonging  to  them. 


coiiceptitm  of  the  process  of  conjugation  1:  -en  parental  Itiojihores  in 
the  fertiliy.cd  ovum.  We  may  picture  thes.  i)ici)horcs  as  lyinj;  side  hv 
side  in  a  common  cytoplasm  from  which  they  extract  aiid  to  which 
they  give  ions,  so  that  some  side-chains  are  heing  huilt  up  and  some 
dissfjciated.  Of  tliese  side-chains  many  are  identical,  common  to  the 
molecule  of  each  parent;  these  possess  the  fixed  characters  of  the  species, 
thf.-  race,  the  order;  others  arc  unlike,  and  liic.-,f  t\Idently  mark  the 


isni:Hn.\..'  t  »y  \'Vi  iui:i>  ai  \iiA(Tt:RS 


53 


<.lf<nlfH  ami  tlieir  Hule-tliains  will 


■••■-l;:::;;-:;S'rs:;,^::^;l:x;1.^^K.^^s.. 

1  .1  .   T„.itiirc  oiH'vtc  ami   siKTinatoztioii  ea<  li  >muerK<i  a 

iMHTiiiu'iits  show   lis  tnai  tir   lasim.        ••   i  ^i  *  4.i,„  ,     ,.wU 

snrr„mi<lmc  iyt"|il»5"i);   h""'  tl'«>.i"'i>    '^:, "  .l: ■,,,  i,,.,ait„rv. 

tr  '  ■■ni^dTrr  lon«-arVu-a  question.    ;-"^™7-^,;'' .f./^v  t 
teichim:  of  the  mon.lu.loKists  wc  think  that  sonio.  but  not  all,  ma>  t  e 
U       ■    .    n  halioat'ea  before  that  we  picture  the    -f  ""^.  J   "'^ 
<  in  interaction  with  the  cytoplasm  that  surrounds  >*.  pmg    P  to 

H';5rth:^cr:^r;^Sl-,!<l;np:ia  can  transmit  wh 

;  "'  uSn  he  evident  that  there  are  some  kincls  of  aej-men  t^^^^^ 
.an  he  transmitted,  and  son.e  that  cannot.  The  «-'f  ^^  J^'^t^^^^^^ 
i.npression,"  by  which  a  pregnant  woman  ^^"^^'V  tr  /Sk  toThe 
thin.'  which  mentallv  impresses  her,  is  supposed  to  transmit  it  to  the 
prin  she  is  carrying,  is  a  myth.  "Use  f^'n;nremens"  are  probably 
nut  transmitted;  by  this  we  mean  that  .^^^^  .  We  hav^  iot  as 

repro,hK.ed  in  an  unusually  large  biceps  m  his  son.  VVe  have  not  J 
Net  definite  evidence  that  acciuired  immunity  can  be  transmitted, 
•  hhouglahe  offspring  can  obtain  immunity  during  intra-utenne  growth; 
to  prove  that  immunity  can  be  transmitted,  u  wou.r  -f 


neoessarv  to 


-y. 


54 


INTRODUCTORY:  CEl.l.s  A\n  TISSCES 


have  only  the  male  parent  iiiiniunizcd,  and  to  fintl  the  propcny  so 
immunized.  It  niijrlit  almost  he  i)rediete(i  that  imnnniity  wonld  he 
transmitted  according;  to  tin-  Meiuieiiaii  law,  some  of  the  ])roj:eny 
being  immune,  others  not.  Mutilations,  loss  of  linihs,  etc.,  are  not 
transmitted.  On  the  eontrary,  there  is  a  series  of  retrogressive  ehanges 
in  the  tissues,  the  result  of  toxie  intluenee,  wiiich  does  seem  to  he  able 
to  afTect  the  i)ro{;eny.  For  example,  it  seems  as  if  the  drunkard  hegets 
children  who  are  the  worse  for  his  h:il)it;  we  need  scarcely  ])oint  out 
how  difficult  it  is  to  j.rove  this  statistitaily,  because  there  are  so  many 
factors  to  Consider,  such  as  these:  the  mother,  being  sound,  may  domi- 
nate the  ott'spring,  and  the  child  be  normal;  if  the  child  be  abnormal, 
can  we  say  that  the  father's  alcoholism  was  the  prime  cause?  ^lay 
it  not  he  that  the  father's  alcoholism  and  the  child's  weakness  are 
alike  c.X])ressions  of  an  hereditary  taint  in  i)reviou3  generations  of  the 
father's  family?  Or,  again,  may  not  the  child's  incapacity  be  due  to  the 
misery  and  want  tiiat  so  often  go  with  alcoholism  in  the  homes  of  the 
poor?  It  is  not  easier  in  the  case  of  tuberculosis  and  syphilis;  but 
in  all  these  cases,  as  well  as  in  ])oi.soning  by  such  chemicals  as  lead, 
series  of  cases  do  i)resent  a  liigh  jiercentage  of  nn)nstr()sities,  still- 
births, short-lived,  and  mentally  defective  children.  While  we  think 
that  the  germ  cells  of  the  parent  are  modified  by  modifications  in  the 
constitution  of  the  jiarental  blood  and  lymj)!),  we  nuist  admit  that  the 
germ  cells  live  a  relatively  latent  existence;  that  in  them  metabolism 
must,  for  considerable  i)eriods,  be  at  a  low  st.  te  of  activity,  and  that 
this  low  degree  of  activity  will  tend  largely,  but  not  entire! \,  to 
preserve  from  change  the  biojjhores  of  the  germ  cells,  becaust  the 
interchange  of  the  side-chains  of  the  biophore  with  those  of  the  .'yto- 
plasm  will  not  be  very  active,  and  the  enviromnent  will  thus  affect 
the  bio])hore  only  to  a  limited  extent.  That  it  aifects  it  even  in  tlu- 
slightest  degree  is  sufficient  for  our  contention. 


(HArTKU    11 

THE   C.VUt^KH  OF   DISEASE 
K  tlu-  cell,  the  or,an,  or  the  in.livi.lual.  any  .leviati,..,  from  the 
„„ru.al  is  a  pathological  «'';;l>^';;';-  .^  ^^,^i,,  ,,f  indivi.'.uals,  in  ulmh 

ll,i..  IS  a«|UirC(l,  unless   t  In  tin  '''•''''  ,      ,,     ii„n.,i„„  „t 

„.„,„.l,.-n,  ,.t  one  ..r  "'I'"  l»|;™' ,'^  ,,    '^     ,'  ^  |i,i„,,  is  m,  i„heri,«l 
,|,,s,..    II  It  I.C  siuli ;.  result,  tlK  l'''"  "'"1;   '      |,,,,,,,,i„i  „„„|i,i.,„  te 

;:tii;';:i;-,;:s,;:!;';s:a.y;.s«.ssc,i.n\ns;ure  2'^^^^^^^ 

antenatal  or  postnatal,  aiu    tlu.^e  te%N    xMu  ,  art    '" 
l„p,:,.„inn  to  the  i.ulivi<lual  at  the  moment  ot  h.rth  a^  P"*^^"^'" 

hile  pathological  states  may  he  separate!.  ''^,;;  "I'  ,,;>^  ,^     'J 
,,,i..h  .litVer  from  one  another  in  the    ..hk    '";,':.,  \,^,^^^^^^^^^^^ 

„.„t  .,..t^  it  is  nece'^sarv  to  nc  icate  what  these  causatnt  ai,'ents  an, 
^in      t' s  n  ^^Xsomd  .netho.l  to  consider  them  as  direct  and  pre- 

ii^  .  ™r  -rs  aKo.  physicia,.s  knew  nu.ny  P-  -P-;;;;;!;;- 
hune^-hrect  ones;  today  we  are  hndm,  ont  '-  .1.  c  .  s,  after 
another  (witness  the  speiilu-  mun-orpim-n,-.,  <'  ^^^^^  ;-    ,  . 

^ight  of  the  predisposing  or  assisting  causes.     H.r  exampk.  manx 


56 


THE  CAISES  OF  DISEASE 


iiulividnals  carry  in  tlit-  tliroat  the  gfriii  wliicli  \\v  coiiiit  the  direct 
or  exciting  cause  of  j^ieiimoiiia;  tlie  assistiiij;  cause  a])])areiitly  must 
act  before  a  man  is  attacked  l>y  jincinnonia,  and  tins  assistin>r  cause 
is  not  the  same  in  all  cases,  and  frecincntly  is  entirely  intangible;  we 
hide  our  ignorance  behind  the  term  "lessened  resistance,"  and  although 
this  may  be  as  yet  only  a  name,  we  must  not  fail  to  keej)  in  mind  that 
assisting,  indirect  causes  exist.  It  even  happens  that  the  same  agent 
may  be  at  one  time  an  exciting  cause  and  at  another  a  i)redisposing 
cause;  such  is  cold,  which  at  one  time  frc  'vs  a  tissiie,  and  at  another, 
paves  the  way  for  tlie  inroad  of  pneumonia. 

Predispositions  are  thus  the  result  of  the  presence  of  assisting  causes, 
or  of  the  absence  of  i)reventing  properties.  When  we  say  that  there 
is  in  an  i., dividual  a  i)redispositi()n  to  tuberculosis,  we  mean  this.  We 
have  in  our  mind  a  series  of  generations  of  a  family  in  which  cases  of 
tuberculosis  arise  mofc  frequently  than  in  the  same  number  of  individ- 
uals taken  at  random;  in  this  family  we  note  certain  j)eculiarities  of 
build,  of  habit  of  life,  of  constitution,  which  we  susi)ect  have  a  relation 
to  this  increased  tendency  to  tuberculosis.  An  individual  i)ossessing 
all  tliese  peculiarities  may,  it  is  true,  escape  tuberculosis,  but  his  chance 
of  escaping  it  we  hold  to  be  less  on  account  of  his  possessing  these 
peculiarities  and  the  history  of  increased  incidence  of  tuberculosis 
that  has  arisen  in  conjimction  with  them.  We  say  that  such  a  person 
possesses  a  diathesis. 


INHERITED  PATHOLOGICAL  STATES 

It  may  be  rei)eated  that  the  results  of  all  the  morbid  influences  which 
bear  ui)on  the  foetus  in  the  womb  are  accpiired;  mutilations  are  never 
iidicrited,  and  the  statement  may  be  safely  made  that  infectious  disease 
in  the  parent  cannot  be  iidicrited  by  the  child  although  it  may  be  com- 
municated to  the  child  in  idem.  The  cases  in  which  children  are  born 
with  tuberculosis,  syi)Iiilis,  smallpox,  or  other  such  diseases,  are  cases  in 
which  the  child  has  contracted  the  disease  while  in  the  mother's  womb. 
These  diseases  arc  transmitted  by  some  germ,  known  or  yet  to  be 
discovered,  and  to  say  that  they  could  be  inherited  means'  that  the 
germ  nnist  be  in  the  spermatozoon  or  the  ovum  as  a  foreiiin  body, 
for  we  cannot  imagine  it  as  being  incorporated  with  the  protoi)las'm 
o*  the  s])ermatozooii  or  the  ovum  and  retaining  its  individual  power 
to  cause  disease;  but  it  is  not  conceivable  that  a  mimite  germ  cell  with 
a  bacillus  or  a  ijmtozoiin  inside  could  i)erform  the  delicate  function 
of  fccmidation.  .\s  readily  should  wv  look  for  good  time  keeping  in 
the  hatter's  watch,  which,  it  will  be  remembered,  was  full  of  the  best 
butter.  It  is  true  that  in  animals  where  there  is  a  large  yolk  with  the 
egg.  the  yolk  may  become  infected  almost  innnediiitely  jifter  fertiliza- 
tion, as  hai)pcns  in  the  ticks  that  cause  Texas  fever,  and  as  is  seen  in 
the  eggs  of  exjjerimentally  tuberculous  hens;  but  the  human  ovum  is 


<:-j.  ViKi  Ati.w-r-f  i=ifr^-;-'^ 


INHERITED  PATHOLOGICAL  STATES 


57 


1      e       (,...r^  volU  thrtt  infection  of  it  can  scarcely  happen 

r "'r:  ,:;Js"rs\  tuS « happen,  «ouid  i.  !«.»„  .1. 

;';„;i; ';;;  ii.;:  "«<  *«  u  incomes  »„  c,a„,pie  ..f  >  pati.oK.gK-ai 

"■;;''•'?•  ""i^li'^LrsVcSSase.  ■»  tnl«re,.U»is  ,.r  syphilis  are  „c,t 

sti^'niata,  snih  as  tlutcmnbon  &  it-c  because 

i,..lirectly  due  to  syph.hs;   these  .^J^^  T,f  c^l  eH  n^^^^ 
syphilis  has  existed  in  the  P«^^"*- •"'\\f;'  ,;;",,^"''.:^  ^^  ,vav  k-cogm/e 
a\  least.  parasyphiUtic  '-'^^    ^^.^j.^"  Jj;'^,  ^ ha^^     r  a  .eak  fn.me. 

^tt;rf;:::er:;.siits:n?di:t;^^ 

,.It  Sai  .manifested  in  various  vs^^l;.|end.n,^^^ 
of  the  disease  in  the  one  parent,  and  the  relatu  t  actn  u> 
plasm  of  the  other  parent: 

1    Sterility,  no  off  spring  being  produced.  •       *     r«^   intra- 

'V  I  nperfV^  development  of    offspring,   g.vmg  nse    to     a)     nt  a 
.'        ^ntl,      r  (b-)   nhvsical  malformation,   (c)  lowered  resistance, 
iiternie  death,  v,r   W   pinsicai   •       ,,,  ..j^"  ;„  ts  nature. 
„r  s„  Frequent  occurrence  as  to  he  callei      parasijecinc    u 

:;.  Imperfect  development  of  offspring,  appearing  later  than  the 
succeeding  generation. 

4.  No  apparent  effects.  ..hereis  undesiraWe  qualities  may 

I'atel  the  quality  of  o„mha,i„B  u  ""«";■  ;?-|X!^„«t    ti 

Generations.-lf  abnormalities  can  be  transmitted,  f  ^  "  ™\^^ 
uenemwviua  ,,ftener  thev  appear  m  a  series  »)f  progditors,  tne 

mil  erstood  that  the  outlier  tiitN  111  j  wwimnt  •itteniDtini' 

™r,'"* ",'  ■^  r.::?eX.T™wMinis'-;:,»i  wmo. 

S  i^ll;:':;;:    ;  ,    •      .;;,  l  heri,a„«s,  bu.  .l,oy  pr„l,al,ly  are.    To  ^ 

a  premature  exhaustion  ..f  nerve-cell  groups,  but  M^V*  '/"'l  "  "  en 
;,l',o  function  may  really  have  a  strictly  anatomical,  if  >et  unseen 

'"itheses  While  we  deny  the  transmission  of  infectious  disease 
l.'^J'^^ipl^n  Ve  admit'that  an  attack  of  jn^-tion  ma^^moch^ 
,lH.  nexr  gennplasm  for  better  or  worse.  -  ^he  'hreaion  of  gnu^tle 
i.lVspring  greater  protection  or  greater  liability.     We  are  unable 


•t8  fiik  (\\rsh:s  OF  disk  as  i-: 

lociilizc  this  quality,  jiiul  prohaMy  \\f  sliiill  never  iin(lerstaii(i  what 
it  is,  l)ut  as  a  result  of  it  there  is  the  existence  of  "raeial"  diatheses, 
or,  stated  otherwise,  the  ahseiiee  of  raeial  iminmiities.  The  Hebrew 
has  a  eertain  racial  freedom  from  tiihereiilosis,  and  a  raeial  liahilitv 
to  metaholie  distnrlianee^  sneh  as  dial)etes  and,  in  the  female,  oliesity; 
the  white  rat  has  a  raeial  freedom  from  anthrax,  and  many  eariiivoroiis 
animals  from  evil  results  of  septic  wounds.  A  man's  oH'sprinj;  inherits 
from  him  (|iialities  which  render  it  lialile  to  or  exempt  from  a  eertain 
disease  jns^  as  it  inherits  a  likeness  of  feature.  We  cannot  take  two 
needles  and  tease  out  of  an  ovum  the  i)articular  i)iece  of  protoplasm 
that  i)ossesses  these  potentialities;  hut  there  is  scmiethiiif;  actual  in 
the  germplasm,  in  the  relation  of  one  part  to  another,  or  in  the  mole- 
cular };roui)in>r,  that  constitutes  a  real  hasis  for  the  "diathesis";  and 
when  we  k<)  farther  and  find  that  diseases  such  as  hysteria  and  epilepsy, 
which  we  fretiuently  name  functional  diseases,  are  inherited,  we  realize 
that  there  may  he  a  chemical  and  celhi'ar  basis  for  the  transmission 
of  "nervous  diatheses";  but  if  we  cannot  find  the  ortranie  change  in 
the  tissues  of  the  diseased  individual,  it  is  yet  more  futile  to  attempt 
to  find  it  in  the  germplasin. 


INTRAUTERINE    AND   PARTURIENT   CAUSES 

Morbid  Conditions  Acquired  in  the  Womb.  Wuh-lv  var\ ing  results 
accrue  from  influences  acting  u|)on  the  embrvo  or"  the  "ftetus,  and 
although  the  morbid  states  will  be  discussed  ironi  the  standpoint  of 
causes  rather  thai,  results,  it  is  well  to  indicate  what  these  results  are. 

1.  Death  ol  the  embryo,  with  abM.ri)tion  or  "blighted  ovum"  or 
abortion,  the  ffvtus  l)eing  imperfect:  or  premature  labor. 

2.  Monstrosities. 

■  \.  Malformations  of  excess  or  of  defect. 

4.  lm['aired  vitality,  with  imperfect  development,  without  gross 
anatomical  change:  ui)  Ceneral  infantilism,  etc.  (b)  Svstemie— 
es|)ecia!ly  of  the  nervous  system. 

5.  Cachexia, 
b.  Infection. 

7.  'JVauinatism. 

On  the  other  hand,  if  we  classify  the  causes  that  lead  to  the  above 
results,  we  hn<l  that  tli.-re  arc  certain  influences  actinsr  ou  the  embrvo, 
as  follows:  • 

1.  Physical  and  mechanical  causes,  including  injuries. 

-.  Malnutrition. 

■i.  Intoxications, 

4.  Infections. 

1.  Physical  and  Mechanical  Causes,  By  violer.t  .baking,  ihc  egg.  of 
certau,  mvertebratcs  in  the  four- or  eight-<-elled  .stage  may  have  the 
indiMdual  cells  wholly  separate<l,  with  the  result  that  each  cell  mav 


ISrUA-fTKl^l^I^  ASn  I'MnlRIKST  rMSES 


50 


.iv..  n.  t..  a  ......Pi.te  i,..i.vi.u.a,  ..r  i^i^^ -;'--' -;';.;:;  i^l;;: 

,,,„..rnu.liti.s,  l''-p''""'''>  ''-^/y  ■;  ,;ralU-l  facts  i..  the  ca..-  c,f  the 
'-  ^"  --^''--  '>^'^  ^^Vt;  know  Cover,  that  when  the  a.nnmn 
•"="'"""'"'"  *"'"■•"■  \.  ....  ,n  pressure  hn.ui^ht  t..  hear  uih.u 
.„  i„....,n,.lete  there  .nay  ^^^^^'^^,^,,,,  ,,„hry..  an.l  ann.u.n 
,,„,  ,„,,,ry.,.  ..r  a.lhesu.ns  ma  »^  "\  ;^,,,,„^l,,  the  movements  ot 
,.ru.hu.in,  n.alf..nnat,ons;  "-»  j^  J;;.;,;;^;";.,  u.i.t  hn.hs  are  thereby 
tl'^'  t"tus  may  rj-ul    h'  K.      ^  <^        .^^^^^^^^  ^^_^^.  ^  ^  traunu.t.sm. 

„„,.utateil.     l-.etal  iratturcs   "^  fraeilitv  of  the  hones. 

not  so  caused.  ,j.w.,.„t-.  also    nutritional  defects  in 

^Vhc.,  there  is  .hsease  ot  the  ,  au  U  ^^^^'^  ^^^  j^^^^i  i,,,„„, 

,he  fcetv.s  are  very  rea.liU  ^^^^^^ ^^    Fvt    where  a  monochorial 
„  imperfect,  and  ^'^al  .Jc.ah  n.^^  J^nsn^^    1  -«         ^^^^^^^  ^^^^^^.^^^  ^^^ 

nvin  pregnancy  exists,  that  is,  ^^^^^^^^  ^'>^;^.  \  „,,,re  than  its  share 

lu>edVlacenta.  the  more  -S^'"™^^,;;,*;;,"  £,;  •     ,,U,ocl  by  anastomos- 

"'■  ^''^'  '^'"■"•^^"'  ^'r''^"'";';;-;';    1?  ev  o     ts  weaker  companion,  w^iose 
i„.  vessels  into  the  umb  heal  '^^^^"^  ''',  ^^j^^^;,,,,  ^^es  rise  to  aulema 

'"rUcations.-  U  has  been  experime,..dly  r^^^^^J^Z 
snch  as  lead,  mercnry,  arsenic,  carbon  mo  ox  dc,  nrp^  •  .^^^^^^  j,^ 
p;,.s  through  the  placenta  and  can  ^  ;  '^;;  /  ;,,,ne  or  epileptic; 
l„.l  ,,ois..ning  the  oHsprin,  IS   "'^l"       >,^;;^^,^  V  expose.l  to  lead 

,,..,  it  has  been  shown  that  wht>re  -^  J^  ^  ,^.,.,,,,,  .iu.lren;  in  :r2 
Mhsorption,  NS  presinanc.es  resulted         '  exposed  to  lead  poisoning 

pregnancies  where  the  lather  :'l«'f  Z/;' '  ;i;7,''J^^^  in  a  lar.e  series 
!„.ly  3  of  the  olTspnn^'  survived  » «•"•  ^'^^  ,  .'Rentage  of  aborticms, 
of  dcoholie  mothers,  it  w>^  Unuu\  t''"^;';.  j";.^  J'  %,,,  „early  two 
.tillbirths,  and  children  dying  before  the  tli  d     tMr   >^.   ^  .^ 

„,1  one-half  times  as  great  as  normal  ^^^.^^  ^  ;: /f^,,^.  ,,ter  offspring 
.ressiyely  a  victnn  to  .dcohol^    h    h  death  .  ^^^^^^^^  ^^^^^ 

niul  the  lowered  vitalit\   ol  ^"^  "'"*■,.        .  infect  bus  <lisease. 

4.  Infection8.-\Vhen  the  '""tl-r  su  er    fn. m  au  "  ^^^^^^, 

the  absorption  of  toxms  by  ^^J^^^^^M  with  the  cases 

irreat  to  result  in  its  death,  a  state  o      "  infective  agent 

nst  .leseribed.    But  occasionally,  t^'"  'f^  '      J^'  ;;;^^\  ,th  the  .lisease 

Lds  its  way  into  the  fa>tal  t'-"^.!'' »'",^  ^'^^^^^  ^"  I    cTrefuUv  excluded. 

T'  f:'::'^i:::^.n^\r:^      -y  of  syphius 

there  ^ et  r.uuim  inst.ir.< es  V  ,        ,.     tuberculosis,    varicella,    variola 


60 


THE  C.WSKS  OF  DISKASH 


typlioitl  fcvtT,  (lidlcni,  «|)i(l('iiiic  (•on'l>r(is|)iiiiil  nifiiiiijiitis.  infliu'iizji, 
rt'lapsitii;  IVvt-r,  inalaria.  and  yellow  tVvcr.  'J'lic  fX|)laiiati()ti  of  these 
cases  is  i)r(il)al»l,\  that  a  ^ross  lesion  of  the  harrier  lietween  the  maternal 
and  fcetal  circnlations  oecnrred,  and  not  that  the  eausative  agent 
"filtered  through. " 

The  Effects  of  Placental  Disease  upon  the  Foetus.  I'he  placenta 
is  essentially  a  part  of  the  fietus,  and  is  a  mass  of  finger-like  i)roj»'c- 
tions  (tlie  villi)  of  tiie  outer  coat  of  tiu-  f(etal  sac  into  the  uterine  wall; 
the  epithelium  of  these  finger-like  projections  has  great  phagocytic 
power,  and  ahsorhs  the  tissue  of  the  uterus  until  each  finger-like  pro- 
ces  ines  to  lie  in  a  large  hlood  sinus  of  the  maternal  organ.  Kacli 
fir.,,,  like  process  contains  a  vascular  loop  and  the  f(ctal  hlood  flow- 
ing in  this  loo|)  exclianges  wit!i  the  maternal  Mood,  oxvgen  and  other 
difVnsihle  materials  through  the  wall  of  the  villus. 

Jt  is  ohvious  that  these  finger-like  processes,  with  their  phagocytic 
power  tend  to  weaken  the  walls  of  the  maternal  sinuses,  so  that  hemor- 
rhage is  apt  to  occur;  in  fact,  normally,  hemorrhages  do  occur,  forming 
accessory  sacs  into  which  new  villi  make  their  way;  with  heiijhtened 
maternal  blood  pressure  or  with  maternal  tissues  ill-nourished,  extensive 
hemorrhage  may  occur.     .Such  hlood  heing  effused  gives  no  oxygen 
or  nutrition  to  the  f(ctal  hlood,  and  hy  its  very  presence  prevents 
wholly  or  ])artly,  the  normal  circulation,  so  that  the  Actus  may  peri.sh 
from  asphyxia.    This  is  a  cause  of  premature  labor  and  stillbirth.     If 
the  hemorrhage  be  not  sufficiently  severe  to  bring  this  about,  it  will, 
nevertheless,  be  followed  by  thrombosis,  and  finally,  by  fibrosis  of  the 
areas  affected.     This  will  reduce  the  area  availahle'for  the  nutrition  of 
tlie  fo-tus,  which   will   necessarily  be    imoaired.     Impaired   luitritiou 
ot  tlie  id'tal  structures  may  be  cxcmpliHed  in  disease  of  the  finger- 
like  i)rocesses,  the  villi  themselves;  they   are  at  times  a-dematous 
c.xstic,  or  they  may  become  i)artly  fibrosed,  anv  of  which  conditions 
inay  give  rise  to  i)rcssure  upon  the  vascular  looi)s,  with  consequent 
li-sscning  ot  the  efficiency  of  the  circulation.    The  nutrition  and  growth 
o    the  ((ctus  thus  ai)i)ear  to  depend  directly  upon  the  amount  of  good 
placental  tissue,  and  the  more  numerous  the  villi,  and  the  more  active 
they  are  in  i)liago(ytic  proi)erties,  the  better  will   be  the  mitriti(.n 
and  the  greater  the  growth  of  the  child. 

Of  iiifecti(.ns  of  the  i)laccnta  the  most  important  is  svphilis  In 
this  there  is  cellular  overgrowth  of  the  villi  with  o'dema,  .•uul  both 
ot  these  leaturcs  tend  to  increase  the  size  of  the  i)lacenta.  Thus  in 
syi)iulitics,  the  placenta  max  weigh  half  as  much  as  the  chil.l,  althouuh 
m  normal  persons  its  weight  is  about  .mc-fifth.  A  pmn  chil.l,  of  eourse 
IS  partly  rc',p..nsibie  for  this  altered  rati...  Multiple  small  abscesses 
are  als..  frequently  f.,ni,.l  in  the  sypliilitic  pla.rnta,  an.l  the  co-existence 
ot  these  with  the  changes  menti..ned  above  is  characteristic  To  the 
eye,  the  p  acenta  i^  large,  pale,  an.i  may  have  yeii..wish-white  Hbroid 
areas.  A  turtlier  .hara.ter  in  syphilis  is  the  leukocytic  infiltration  of 
the  umbilical  cord. 


■.\ai 


^^o^■STRosITI!^:s  and  abnormm-itiks 


61 


Hydiamnios    (excess  of  an.ni..fu-   ttnu\)   often   arises   in   syi.hilitirs, 
,,?S.  .-.li"''  .U-r-ts.of  t..e  f..;t..s  .nay  ^aiso  •--  .  ;    .p;.~ 


of  anmiotic  Hiiid)   is 


also  sometimes  a  result  of  syphilis. 


i("((i(ieii<v  oi   anmioiif   ihiki/    -^  ••■•'■    ■ ,  ,  i    /'    »    i. 

lionnally  Ion,  eonl  n.ay  l.eeo.ne  knotted,  an.l  so  <•»-"';-; 
,„  „  ,nav  Nvin<l  around  tl.e  f.etus  eompresMUfi  or  ^roovu.,  the  1.  .1^ 
l„l.s    the  eou.pressiou  l.ein,'  associated  ^v.th  the  atrophy  eonse- 
,u   t   uK.n  ohstr..ete.l  l,loo.l  How;  an  ahnormally  short  con    ma 
•rlenxvith  lal.or;  and,  finally,  the  amn.on  may  be  fused  to  the  tcetn  . 
//rise  to  iKUuls  an.l  so  interfering  uith  the  growth  of  some  part 
:,r  l,v  ohstructinj:  veins  or  lyn.phaties  may  even  cause  a   locahml 

"""The'catlses  of  Pathological  States  Acquired  During  Parturition.- 

Tl„.  causes  of  these  are  mechanical,  traumatic  or  .ntect.ous.    IMechan.eal 

'  „.,s  are  either  shortness  of  the  cord,  preventu.g  descent  or  producniR 

t  anLmlation.  or  undue  narrowness  of  the  pelvK-  channel  car.smg  pro- 

.  H  'ahor  and  the  results  that  arise  therefrom.    Traumat.c  causes 

n  tl  c  n.anual  or  instrx.mental  aids  that  may  he  necessary  to  complete 

.      n,cess  of  parturition;  such  also  is  the  pressure  that  produces 

:„.lton,a  of  the  scalp;  such  the  accidents  that  hru,,  »  >'>''t  ^--t^'^ 

„r  .li^locations  of  hones,  or  l.irth  pals.es  or  hydrocephalus.    The  ch  e 

i,„,.,ious  cause  is  the  presence  of  pathogcn.c  organisms  m  the  gen    al 

tra.t     especiallv    the    gonoeoccus.    leadu.g   to    ophthalmia,      tnallx, 

i.nproper  treatment  of  the  uml.ilical  cord  may  lead  to  hemorrhage, 

1„.  al  suppuration,  or  to  general  hactenemia. 


MONSTROSITIES   AND   ABNORMAIJTIES 

The  terms  denote  grave  anatomical  departures  from  the  normal, 
either  general  or  local,  and  the  term  monstrosity  is  applied  to  the  more 
pronuuneed  of  these.  Departures  from  the  anatomical  nornia  co.^^t 
;,t  V  nriations  either  in  the  direction  of  excess  or  ot  .letect.  or  ot  altered 
relative  i)osit ion  of  parts.  ,•.!••  ^t  +!,„ 

Abnormalities  of  Excess.-This  may  show  itselt  in  excess  of  the 
iii,|i\i(i)ial  or  in  numerical  excess.  /n  i  *„r.ji 

i„.livi.;ual  excess  may  be  («)  universal,  ,.r.    giantism;  (h)  lateral 
.  ,     where  one  side  is  larger  than  the  other,  as  if  there  had  been  unequal 
,ru isi..n  when  the  first  two  hlastomeres  were  formed;  or   c)  oc"'-  ^^h^ 
„„e  n.eml.er  or  organ  is  markedly  larger  than  the  stand,  rd  set  by  the 
..  .t  of  the  bodv.     Giantism  applies  to  those  huinan  individuals  uho 
:,„.  more  than  200  cm.  high,  that  is.  (i  feet  ^  inches,  a  height  tha    is 
MMllv  due  to  the  great  length  of  the  legs,     (..ants  usually  spring 
l„„n  tan.ilies  in  which  the  individuals  are  of  medium  height.    Lateral 
M;,„,is.n  cannot  well  be  extreme.    Local  giantism  may  either  be  true 
.  ,.  ,„.,,.  ,,,.  ;„.o„ired  bv  disturbed  nutrition,  in  which  latter  case  it  is 
,i,e„;,f  <.ongei.ital  origin.    Thus,  localized  elephantiasis  of  a  limb  or 
macroglossia  or  macrodactyly  (where  a  finger  is  abnormahy  large)  may 


mjf. 


^■^' 


■STT 


^mi^m-*m^?^^mm^mi^i 


62 


THE  CMSKS  OF  [)ISi:.\SR 


1)0  due  to  ohstnictinii  of  tin-  Iviiipli  (•liimiicls.  and  cDiisi-qiirnt  over- 
j;r()\vtl)   of    coiiiHM'tivi-    li--Mif>.     Wlien-,    li(.\vf\tT,   tlu-rc    is   not    only 

marrodactyly  hut  diiplicati. f  tiiipr^  or  a  tcndrncy  tiuTcto,  it  i>  -ate 

to  assunif'tl'iat  tiicrc  lia-  Imcm  a  ri-diuidamy  of  vcuttativc  luattt-r  at 
the  jrrowiiij:  point.  Hypertrichosis  (hairiness)  ami  lipomatosis  (,i;encral 
oht'sity)  ar,'  to  he  explained  liy  a  coiuiiination  of  inlu'ritanee  aud 
nu'taliolie  Modifications;  precocity  in  the  ilevelopuicnt  of  the  nuiscnlar 
and  ne;'  ve  systems  ai)pears  also  to  i)e  associatetl  with  al)errati(tns 
in  deve,u|.. .lent  of  the  ductless  irlanils. 

Nuinerieal  excess  inelmles  a  wide  ran>;t'  of  al)nornialities  from  midtiple 
hirtlis  to  i)artial  du])lication  of  a  phalanx. 

Twins.  Twins  may  lie  dichorial  (heteroi'iphal)  or  monochorial  (mouo- 
oi)lial).  In  tlie  former,  each  child  has  its  own  membranes  and  placenta, 
although  the  two  placentas  may  ultimately  fuse.  The  chiltlren  may 
or  may  not  he  identical  in  sex;  they  may  or  may  not  closely  rescmhie 
one  another;  in  fact,  they  ohviously  arise  from  two  scjjarate  ova  fer- 
tilized at  the  same  period.  Should  the  dichorial  twins  he  of  the  saine 
SOX,  and  very  much  alike  in  characteristics,  it  may  he  that  two  ova 
from  the  same  follicle  have  heen  fertilized,  for  multii)lo  ova  in  a  follicle 
do  occur;  there  is  even  one  other  possihility,  that  a  siufjle  ovum  after 
fertilization  has  divided  into  two,  and  that  the  two  halves  hecome 
sei)arately  implanted  in  the  uterus.  Superfoetation,  in  which  the  omhryos 
are  of  ditl'erent  apes,  ohviously  can  arise  only  from  ova  discharged  and 
fertilized  at  difTerent  ])eriods. 

Monochorial  twins  are  rarer  than  dichorial.  Thoy  have  the  same 
chorion,  the  same  i)lacenta,  are  of  the  same  sex,  and  if  ei|ually  developed, 
much  alike.  .\s  the  chorion  is  the  outer  wall  of  the  ovum,  it  is  evident 
that  here  the  same  ovum  has  jjivon  rise  to  two  indi\  iiluals.  Such 
twins  may  even  have  identical  ahnormalities,  stuh  spina  hifida 
or  hyi)os]tadias  or  right-sided  hydrocele.  FAi)eriineii'  u])on  inverte- 
hrates  and  even  upon  the  lower  vertehrates  has  dt  uionstrated  the 
possihility  of  one  ovum  giving  rise  to  two  individuals,  and  the  eggs 
in  development  may  even  he  shaken  apart,  when  dwarfed  individtuils 
arise  from  the  fractions  of  the  original  individtud.  The  possihilitios  to 
which  monochorial  twins  are  due  are,  then,  these:  (1)  the  two  nuclei 
of  one  ovum  may  lie  sejiarately  fertilized,  or  (2)  a  fertilized  ovum  may 
hreak  in  two  at  a  very  early  stage,  as  for  exami)le,  when  it  is  two- 
celled,  or  CJ)  a  cleavage  of  the  germinal  area  at  a  comi)aratively  late 
period  may  give  rise  to  two  primitive  streaks  ui)on  the  one  germiiuil 
area. 

r>iiiiiiiil  Twins.-  Thi>  covers  a  numluT  of  cases  in  which  a  common 
fciuure  is  that  one  of  the  twins  is  nornudly  formed;  the  other  may  he 
a  iuni])  of  flesh,  with  smaller  warty  j)rojections  on  it  (not  unlike  a 
])otato  with  small  suiieruiunerar\'  tiihors  upon  it),  whose  only  claim 
to  recognition  is  tiuit  the  umhiiical  cord  is  attaclied  to  it;  this  is  the 
fcBtus  amorphus.  .Sometimes  there  is  a  fair  indication  of  the  lower 
limhs  hut  no  head  (foetus  acephalus),  or  the  tu-tus  may  consist  of  little 


MoSSTROSrriKS     ..   />  .lW.VOff.Uir/ 77 /^N 


63 


tl.n,  tl.r  cli.Tn»>-lik*'  iH-a.l  (foetus  acormus);  tlu-  nl.snue  ..i  a  hiart 
'".,.■  asses  U-a.ls  t..  tluir  U-\n^  calU.l  m>  ar.l.ac  ...  a.1.1.- 
'"  "•""■.  r.l    t  ...tive  ..a,..es       In  s,„„r  <ases.  like  f.i-tus  ar..rm,.>s. 

;i;;;^;;;;!r;;':;ii;;iy ;;;:.;  rpia..n.,a  wit......! ,.,.  i..t.rvo..ti.... .. 

"'^■rltl'  ;rth.se  acanUa.-  .,.o..strositi.s  is  that   th.-  c-in...latio.. 
Ihc  (aiiM  r..v..r^.Ml  oiif    hera..sr  t  .o  strniim-r  ot  the 

'" ^''^•';;" ;;r;';:: .e .  i  .;^  e i;!;;.;.i u.r....,h i...th; the aiia,.t..ic 
;:;ni:; ";;;;.;  ;^::irL....e  Uy  a,.ast.>.n..se<i.  a...!  the  stn.,„er 


,l„.„„,...nibr,v.ie'  n.e.vcs  lhn,uuli  thr  v„lk  %.  ss.  13  m  r  „,.,,,.,.,,.    ,.„,!  tl.P  later  devlopina 

,  „,,,v„  ,.      A»  a  r,.s,.l,.  its  allan.-i.  ,.ir.ul»..on  ...v.;  ■.,.     .n,.o  ^        '      J"        _^„^_,„„.,  ,.,.,„,,  .,, 
,„:,n,„„.  ar.ery  „f  .h.  sn.,.M.r  ..n^,rv„  ""-;;— ^l^u, IIk.  ennr.'y  ......i.  .h-"--""'- 

:;;:::;::;;ri;:;'^u:';;:7;;"  ::r!;::,"t- r -.... ....  ...,...„„ .., .....  ..„..  cu...„. 

;,„.l  .T-'  imlicalo  llif  amniotic  «.os  ,>f  tlic  embryo.. 

t.in  .irives  hi 1  ,.n.gressiv,.iy  i..to  ...ore  a,..i  ..u.re  ''f  t;-;;;;-^";;;:;;;';;- 

,i,„llv.  i..t.,  the  weaker  ejuhry's  u.iih.heal  arter>   "'''I  '  ?    '  J  ;;.^^^^^^^ 
i,  i,  .listrihute.!  i,.  the  hra..ehes  a.al  ..mmshes  the    ,ss..es  o^         -^ik 
,  n.hrv.,;  it  ...av  he  suttieie,.t  t,.  .amr.sh  a  part  '7'> ;  'X*'*    X,, 
■  he  weaker  e.nl.ry.rs  fra.„e  ...uU-r^yes  aplas.a  a,..l  ;'  ^l''    .^jj  ^.'^  ; 

,1  th,-  we'.ker  e  i.hrvo  hv  arreste<l  aeti.m,  .i.e.....plete  i(t.ut>  a.... 
:.!  e  m;.;^!  no..rish.ne,.t  fails  to  .l.wel.M.,  ^S'lV^Jn  "Jvo 
,).-    it  vet  l-ep'^  as  its  ..w..  provi.iee  the  hea.l  e..(l  ..t  the  tm.  r> o, 

;,;;     t'  ,m,  ri  hes  t^,is  so  ha.Uy.  that  the  .vphalie  e.ui  .>  ...-re  pru.a-  lu 
i:„;ai;rdope.l  tha..  the  caudal  e..a-tottis  acardiacus  anceps. 


^m^. 


64 


THK  (wrsKS  OF  i)ist:ASK 


Triplet,  and  Other  Multiple  Births.    Triplets  ...ay  Ik-  .n..„.K.honul. 

or^!'Z\^l\  an.i  .li.l.orial.    ..r   evc-n    ..oly.lu.nal;  tl-  ruU-s  as    o 

em  tv  of  sex  an.1  si.nilanty  of  .l.anu-U-ristu-s  w huh  apply  to  t«n.. 

Sv    lis,    to  triplHs.    S.V.M  thiMrn.  at   a   h.rth   .s  rvporte..   upon 

Slhle  1"  Jmh^Hty.      In  tin-  .at.  the  n.onoehorial  .levelop.nent  of  ftve 

''S:  Sli;^:     There  has  heen  for  ,„any  years  nuu-h  .liseussion 

up^"  e  rV^sons  for  .li,.l..,'enesis,  an.l  in  a  Hel.l  where  so  >-■;>;. t^^;;^- 

iist  ^ve  venture  to  i.nt  forwar.l  l-ut  one.  which  we  term  the    growing- 

p^^t"  t  K^  rv     This  is  hasea  upon  our  knowle.lj;e  of  the  growth  of  a 


,„  ,.r„n  .,(  ..■.,,„„  of  ,l,o  «r„«,nR  p.iin.  ..f  a  plant.  A.  A.  th-  npicl  .-ells,  which  contmually  divid... 
scctmdary  groning  point. 

pluit  If  we  consi.kr  that  the  first  cell  is  divided  into  two  and  then 
four  and  each  of  the  four  again  int..  two,  we  find  that  the  two  poles 
ten.l  t..  l..r..n.e  separated.  .)ne  from  the  other,  and  each  pole  is  advanced 
l)v  the  c,lls  thitt  arc  l.uilt  in  l.ehiiul  it.  There  are  in  the  plant,  from  an 
earlv  stafie,  two  prin.arv  };rowing  i)..ints-the  supen..r  f..rmiiig  the 
stalk  an.l  the  inferi..r  the  root;  the  <;ntire  plant  arises  fr.mi  one  or  other 
of  these  "ii<m.t^.•'  and  the  -nnvinfj  point  is  the  most  a.Kanced  part 
of  the  plant;  the  ph.nt  increases  hy  growth  hackwar.l  and  not  forward 
fr..m  the  gn.wing  point,  whose  positi.m  is  thus  fixed  at  the  apex. 
The  gn.wing  p..int  ,l..es  not  qrou-  forward  hut  is  pr.ijected  tor\varfl 


MONSTROSITIES  AS'D  ABSORMAIITIES 


05 


,.lls  art-  ahle  t..  d.vule  u.  a  *r«"«^'.;^;;";  ^.bsequentlv  arise  from  the 

.,,„,hter  cells,  ^ut  the.r  ^7;;;^'  \„,        ^^^^       ^^j^,     sim.larly  m 

in  a  (  rection  more  or  ess  '»!«'^'*''  r'    .,.  .u_  superior  growinR  point 

Uals  there  are  two  "grow.ng  pomts     th«  «ui^^^  g        ^.^^^^.^^ 

t  represented  in  the  ^^^^i^^nXr  or'hy'SLe  somewhere  in  the 
„f  the  pituitary  body,  and  the  in  enory  extremities  of  the 

sa.ral  region.    Thc^  two  P°'"^y'^^^^^^^^^  the  early  embryo  and 

,horda  dorsalis,  «"  organ  whose  promi«n^^  ^^^^ 

,,.ose  apparent  ""'^-Xl  ^g  of  the  growth  axially,  as  a  scaffold- 
function  may  be  partly  the  keeping  oi  is  j^g  points  from 
„.,  might  do.  in  the  earliest  ^^^^^\-.^^^^^^^^^  the  suc- 
the  very  origin  of  the  «'"^'>- V L^rK  g^^^^^        to  the  different 

;s;n:  tiXt^^^^^^  ---  ^'''' ''' ''' 

limbs.  „  ,.       .    u„  noted  between  the  plant  and 

There  is  thus  a  close  parallelism  to  ''^  J^^^?      ,  j  ^y  the  fact  that 

t!.e  animal  embryo  nor  need  this  be  undub  d-^V^X^^^i^,^  lateral. 

svmmetry  in  the  plant  is  g^"«^«'^.';ff„' ^oth  rules,  and  the  lateral 

,;,,„use  there  are  "r^T,     ?hecau^  cell  division  is  binary, 
svmmetry  is  the  fundamenta  ""«.  Jeca^se  cell  m  ^^^^^^^ 

■  Hut  there  is  u    ""''•''"^^^IfSsarlacUve  through  the  whole 
i„  the  plant  the  primary  frowmg  points  are  «ct         ^^  ^^^^  ^j^       ^e 

i^roT't -;  itHndU'SeTeTciVhe  nervous  system  have  been 

'''^H^iTiperiorandi^eriorgrown^IK^^^^^ 

...  would  have  the  following  «t«^^,°^  JX^^^^^^^  have  already 

neural  canal  which  form  tje  ventricles  of   he  bra.n^  ^.^^^^^^^ 

f.,rn,ed  themselves,  and  the  '"'^'l^'lShL^Tout  into  a  mass  of 
near  the  site  of  the  pituitary  bmly  ^^^^^  tom  ^^  ^^^^^  ^^^ 

tissue.    This  may  actual  y  happen     Jf^^^^^.^^through  the  roof  of 
i,'>    There  is  none  available,  and  it  forces  «s  ^^  »J  »  j,^,, 

r,;.  mouth  to  the  outside  as  a  ^-f  .PJ^^"    n tun^^^^^  ^-"'• 

epignathus.    These  masses  h^ive  a    times  been    ou  ^^^^ 

„na  tissues  representative  of  «"  *  ^  Sro^^-J^oT  uch  a  mass  lends 
hvpoblast.    Thefactoflimbsactualb  deNeloT^  ^01  ^.^^^j^^^u,, 

ailllitional  weight  to  the  supposition  that     . 

uf  the  original  superior  growmg  point.  ^^,        ^^ 

A  precisely  analogous  case  "^^^^.f ,  \^"  ^'.^tum    at  the  extremity 
,„ass  of  tissue  sometimes  "'^f  ^^^^^'t^^^J^'Tmong  ros^^ 
..f  the  sacrum,  called  congemtal  «'^"«J;"*^"j;-,t^tk  and  head  develop 
a  similar  happening  when  an  imperfct  flower  staiK 
-oin  the  centre  of  a  flower. 

5 


66 


TIIK  CM  SKs  O!    l>'St:.\Sh: 


Polar  Dichotomy    (Mnincliii  j   nf   >\u-   dowin^;    I'oints).     In   plants 
there  is  a  liultiliiy  for  thr  jfrowinc   [M.ni-    to   hranch,  as  whfii  a  fir 


^.<l.  i; 


VIII 

D,.Kr:;.„  -.f  y:,n„u.  („r„,»  „(  ....ho.o.uy  „r  ..|...vu«,..  I,  „„r...i  ,„r\,  „r,„:.„v,.  ..n-ak  ,„  ..  M„m.l 
..rea  with  ^  (,  I  ..  .su,K.r,or,  ,.u,l  /  a  /■  ,  .nf.rn.r  Kru>u.,K  p,„nt;  II,  r, -nit  of  c«,lv  d.W,....  ,mv  of 
superior  r.-o».ng  p„int.  the  scparaii.m  :,lI,.,iM,g  al,o  the  U.fral  ro»»  of  nlis  t.ien  ofl  from  tl  ■ 
Krowin«  pent:  III,  l^.te  .h.-hmomy  .,f  su|Mrior  Kr.minit  |.-.int,  only  the  , .  Il»  Kiven  ofT  mo. 
from  the  two  siiperh.r  growing  points  afTccte.l;  IV  and  '  .ii„il:.r  reaulls  .1  ■  irly  i,n.l  late 
nf  ihc  inferior  sr:,T,:.-.s  poim;  VI,  i.ialu.l,  iaie  u„.i,o,.,my  01  ...„h  .u,H;r.ur  "a,„l  ,„'f,T, 
points  -anakala.lidymus;  VII.  early  (eomplel,  dichotomy  mvolving  both  growing  p, 
double  monster,,  lateral  fusion;  VIII.  mesodidymus.  the  izr  wing  poinu  remaining  sinci 
series  ■  (  cells  derived  from  them  on  either  aide  undergoing  =iti(>D. 


inferior 
■ntly 

>niv 
wng 
..sad 


xmxsrnosiTiES  axd  ABsofV.    ities 


67 


trcf.  Iii>:li  111',  ilividfs  ii.n»  tsu.  ..r 


tlir«;  trunks;  tin-  roof    f  ilv«  radihii 


mii>   sill, 


iliirlv  fork.     Ill  -oinf  plant  ,  a  «livi>ion  mto  i    nuroiH  stems 


b 


lit' 


riilf.    A  pliiiit  ma 


V  t*   IS  uniHTjfi 


(lichut 


»ui\  at 


IHTIU 


I  .lur- 


ing it^  urowtli 
iiiiiiiit 


laUSf    It; 


itwiiij:  iHHiits  ar»"  always  active,  Init  an 


III 


1     ■%  niaiiimal    for  t      mpU     m\b 
tliat   nil  it«Ml  linn    tluri   -i  whirh  «ii' 


Fia. 


iMth 


le  111"',  t 


irrcw  iiiji  iMiinls  are  aetive 
;;»:,  it  has  liteii  r\|K>rinieiitally  sli.v.i! 
■  hfit  as  long  as  tlie  <Mrs;  <-(iiitinues  u, 
>li('«  trnwinK  iMiints,  (iouhl-  monst'Ts 
can  I'l  i>nHline«l  l>>  t)!trti:il  physic.  ' 
(iivisidii 


i    the  exg,     'h  h    a>    may   \ 
'•rniiL'lit  alx'iit  li'    the     re-siin    .t  a  ha 
Mfil    armni'l    it        After    tlic    kTimii  t; 
•  Mii-its  eease,  tlwit      ,  when  ihf  iii''«1illlary 


\c    iiJiK-ars,  III,-  <'an 


iluh, 

Kveii  thei)eri(Ml,  -  it>rt  as  i 
\Miiili   tiichotoniy   n,       i 
ili\  iili'il  into  its  early  ai    ?  i 
the  ilicliotoiny  tK-enr 
-  very  cell  horn  fruin  t 
poi'.t  ill  iTfes  fr  in  it 


loi    er  he 

is,       riiij; 

I  ni.i     he 

[m- .    If 

i\  cmaii''    tiiat 

i|)eri<  -  ii'" 

'i)W, 


i<7itioi     >f  tr    entire  a  litii-Hl,  a     fii 
1  from  the  ii     rinr  grov  ng  poiit. 


K' 

I),  .i  vcsict,- 

■  pan  »,(»»  I  fU; 

.ot<:  1  P.v<      f   right  half      1 

,,w  vc!i,.  f  w'th  '■  ft  half  of  riih.1. 

as  the  cells  which  have 
nti  a  (iichotoiny  has  ot'cnrred 


iin    n  ironi  tne  ii     ri'ir  gn'^    ngpt.u>ii..       un.^  „,,.,  ...-v j  ..«-.  .^ .^■. 

tliii^  earl\ ,  thediv  erKeiicf  nf  ^he  two  gn.  ps  of  cells  hriiiRS  it  ahout  that 


i\v(i  .li\.  rt;ing])riniitivc  -       ikh  arc  foi 
l.'iid  (1(»«!     smd  in  tiifn,  ortrait 

the  duyilicate  of  uios-    thai  ari- 
ll,  hov  '  \  er,  a  relatively  late  ■ 
•I ciirs,  '     ic  en<''!i;h  will  have 
-par     -d  fpnm  one  a '    '  her  1 


mtivc 


and  thus  two anhgeii  vill  he 

li^'  from  each  aiilage  will  he 

ot'  !'r. 

.,y  o!       ■•  of  the  growing  points 

for  I:      two  growing;  points  to 

..^ ells,  w    ich  give  rise  to  a  normal 

■id  til.     iichiitui,  V  can  atlVct  only  certain  parts  of 


x.l. 


l)i(  iiotoiii' 
K  tadidymus; 


t 


A^ 


<e  super    r 
lilt  1 1   anakata 


s  anadidymus  and  of  the  inferior 
thus: 


h:r  1         ,11  animals,  although  not  yet  seen  in  man,  that  the  cells 
le  projected  back  from  the  respective  growing  points  either 


ill 


Qg  THE  CMSKS  OF  DISEASE 

fail  to  unite  or  Leoome  separated,  thus  causiup  mesodidymus,  which 
might  1)6  iuHicatod  tlnis: 


Fin-.Uv  if  the  eleavace  of  l.oth  iinnvinj:  points  luippens  very  early, 
t.!^  paiafiel  ^h.iitive  breaks  arc  .leveiope.1  si.le  by  sule,  g.vu>g  nse 
to  fusional  duplication,  thii  ^: 


a  fiuure  which  dilfcrs  from  anakata.li.lymus  iu  that  the  trunk  has 
two  c-'mplete  i-ngitu.linal  axes  an.l  the  skclct- 1  parts  of  two  complete 

^There  follows  a  larjie  class  of  .h.ul.le  monsters,  to  which  the  last- 
na.ne.l  .livision  is  the  key;  first  of  all,  a  cou.p  ete  c  eavage  has  occurred 
an d  a  secondarv  fusion  has  l.cen  brought  about  between  the  parts  of 


Fin    l!l 


Fio.  20 


If      .'J>1^, 


X« 


Apicopolar  fu»i..n:   dUymmelrical  J.ni-rp^  .( V„l.,|.,il,ura™,.uB.is  ais.vn,.„.uo8  (Schwalbc'.  c^-)- 
The  two  serondary  frmit  ..r  (m.  iai  aspeds  are  Blwolut.-ly  siniilbr. 

the  bodv  which  arc  contiguous ;  the  iignre  last  given  indicates  the 
"Siamese  Twins"  form,  but  it  will  be  understood  that  there  arc  many 
possible  modifications,  as  head  t(.  hea.l.  waist  to  waist,  in  an  axial 
direction,  buttock  to  buttock,  breast  to  l)reast,  and  so  on.  home- 
times  the  directions  of  growth,  and  interference  of  tissues  w.th  one 
another  lead  to  the  suppression  of  certain  organs;  interesting  as  this 
subject  is,  it  is  scarcely  in  place  in  this  volume.    Possibly  the  strangest 


MONSTROSITIES  AND  ABNORMALITIES 


69 


Fio.  21 


Fia.  22 


;ree».       Monouymmetrical  Janiceps 
_„  the  perfect  .econdary  front  view 

',(  eplmloliioracopagus  .uv.uu=j ...". ,..>-...-  -      /•  - -- 

1  .g.  22,  the  defective  aecondary  front  view,  with  ajnotia  (fu«on  of  e. 


m). 


Apa-opolar  fu,ion  >.t  an  angle  lew  (or  greater)  than  180  dcgre. 
'Ceplmlothoracopagua  monosymmetro.)  (VroUk.  case):  Fig.  -1.  t, 
;  .»  ^o  .K.  H.f„Mlve  Becondary  front  view,  with  aynotia  (fu«on  of 


face,  two  arn.s.  and  two  legs  (Figs.  19  and  20).  It  is  to  be  noted  that 
sifcl  fused  monsters  may  be  equal,  or  -^^^r^.^iJ^^u^ 
Inequality  becomes  so  marked  that  one  has  its  frame  parasitic  upon 
liie  other,  the  so-called  teratoid. 


70 


THE  CAVSKS  OF  DISEASE 


kt  - 


DupUcation  of  Organs-  Just  as  tliere  is  cleavafrc  of  tlie  axial  ^row- 
iiiR  points  tliere  may  hv  cloavaKf,  also,  of  tlu;  stroiidary  growing  points, 
whidi  ordinarily  give  rise  to  the  liinhs,  so  that  ahnormahties  ot  these 

arise.  ....       .  , 

Those  ahnornialities  of  execss  may  arise  in  (1)  longitudinal  series  and 
(2)  lateral  series.  Kxeess  in  longitudinal  series  is  shown  by  the  develop- 
ment of  extra  \ertel)ra',  or  extra  rihs;  extra  verleSra-  need  not  have 

extra  rihs  nor  need  extra  rihs  arise  from 
Fio.  23  extra  vertehne;  the  rihs  even  may  show- 

excess  in  lateral  series,  when  for  example, 
the  sternal  end  is  bifid.  Excess  in  lateral 
series  is  oftenest  exemplified  by  Polydac- 
tyly, in  all  grades  from  a  double  nail  to 
an  accessory  <ligit;  p(^lymastia  (increased 
numl  er  of  breasts),  and  duplication  of 
internal  organs  are  familiar  examples  of 
this  abnormality.  .\ccessory  organs 
may  exist  by  true  duplication,  but  more 

Fio.  21 


Thoracic  ijaraai'o  (CJaslruthorHcoixigus 
I)ar!i9iticua).     (W  irltnsDlm.) 


Cycli)|i9  priiptT,  with  nipdian  iiingle  orbit  and  pupil. 
{Mtrr  Ahlfel<l.) 


often  this  is  due  to  segregation  of  certain  cells  from  the  rest  r.f  the 
organ,  which  de\elop  in  some  situation  often  quite  remote  from  the 
original  organ.  The  spleen  and  the  adrenal  furnish  the  most  frequent 
exami)les  of  this. 

Abnormalities  of  Defect.  Just  as  giantism  is  the  expression  of  a 
general  abnormalitx  of  excess,  dwarfism  is  that  of  a  general  abnormality 
of  defect.  The  minimum  height  of  normal  may  be  given  as  4  feet, 
11  inches,  below  which  there  will  be  a  number  of  individuals  who  are 
dwarfs  by  the  operation  of  the  law  of  chance.  .\s  with  giantism,  so 
with  dwarfism,  inherited  disturbances  ot  some  of  the  ductless  glands 
a|)pear  to  be  factors  in  the  imidnction  of  a  certain  number  of  cases. 

Defect  in  Organs  or  Special  Regions.  This  may  he  due  to  (1)  hypo- 
l)iasia,  where  an  organ  is  small  iiicrely  by  relative  poverty  of  the  amount 
of  matrix  set  apart  for  that  organ;  or  to  (2)  polar  h\pogenesis,  wiiich 


71 


MOSSTROSITIKS  AND  ABXORMMITIES 

tlu-  ..ppositi-  .  f  .nclu.t...ny.    Just  as  excess  at  the  growing  point  is 
a„i^,.ste.l  l.>  a  .licl».t.,n,> ,  an.l  the  existence  of  two  growing  pon.ts. 


Fio.  23 


Vll 


VII 


the  niulilli'  line. 


instead  of  one,  so  defect  at  the  gi.wuig  ponit 
nia\  result  in  cessation  of  its  growth,  a  pre- 
,„ature  civing  out  of  growth;  at  the  supenj.r 
pole,  if  tlie  growing  point  die  out,  and  the  cells 
luliind  are  constantly  "'ishing  it  forward,  and 
there  is  no  new  growth  .  cells  in  the  middle 
to  keep  the  lateral  parts  away  from  one 
another,  thev  never  leave  their  state  of  ap- 
proximation,' and  it  may  thus  happen  that 
two  eyes  may  develop  as  one  (cyclops),  or  even 
that  no  facial  parts  may  tlevelop  at  all. 

Siinilarlv,  at  the  inferior  jMile  we  max  hiul 
I,  st-ries  of  defects,  which  in  its  simplest  lorin 
is  si-cn  as  defect  or  absence  of  genitalia,  and 
ii,  its  more  extreme  grades,  fusion  of  the 
lower  limbs  or  even  the  representation  of  the 
l„Nver  limhshv  a  fuswl  f-vL  s  stump  (sympua 
apus).  Rv  a  similar  def  r.  ,.-..  lateral  growing 
points,  arises  syndactyly  :  r  Ai  of  fingers)  or 
ri'duction  in  the  number  ot  ...gits. 
Local  Malformations.— Imperfect  Closure   ol 


iia.  26 


Sirenouielus.     (Synipu*  apm, 
Forster.) 

the    Dorsal    Groove. 


T^^iral  canal  originates  as  a  longitudinal  depression  in  the  epiblas  . 
,1  \!  •  L'lt  lining  the  depression  being  .liflr.^entiated  into  neuroblast, 
1  icl  is  the  precursor  of  the  nerve  tissue.    When  the  heaped-up  edges 


72 


THE  CAUSES  OF  DISEASE 


I'j 


if 
t 


of  this  depression  meet  one  Jinother  they  enclose  the  neural  canal, 
as  if  the  banks  of  a  ditch  o->thiing  it  more  and  more  until  they  met 
over  it.  At  times,  this  closiire  fails,  either  throughout  the  whole  length 
or  in  some  part  of  it.  II  tht  iriiire  to  close  be  at  the  head,  the  vault 
of  the  skull  and  the  scalp  arr  absent,  and  there  is  exposed  congested 
tissue  which  appears  like  a  mass  of  vascular  membranes.  This  con- 
stitutes anencephaly,  acrania,  or  hemicephaly.  It  has  been  supposed 
that  pressure  upon  the  head  by  amniotic  adhesions  at  an  early  period 
causes  some  of  these  cases;  parental  infection  in  others  is  the  i)asis 
for  this  vicious  development.  With  such  cranial  defect  there  is  often 
associated  a  failure  in  the  closure  of  the  spinal  canal  proper— the 
so-called  spina  bifida.  Exencephaly  is  the  condition  in  which,  while 
the  frontal  region  of  the  skull  may  be  developed,  though  receding,  the 
imperfect  brain  hangs  out  through  the  back  of  the  skull.  In  iniencephaly 
the  occipital  bone  is  deficient  and  the  spine  bifid,  so  that  part  of  the 
brain  projects  while  the  occiput  and  the  sacrum  are  approximated, 
the  body  being  bent  backward. 

When  the  lamina;  of  vertebrae  fail  to  unite  the  condition  is  called 
spina  bifida;  clinically,  the  important  point  in  liiis  is  to  know  to  what 
extent  the  spinal  cord  is  involved  in  the  defect.  Cases  of  spina  bifida 
may  be  classified  as  follows: 

1.  Complete  Spina  Bifida-Uere  the  groove  fails  to  close  and  the 
superficial  layer  of  nerve  tissue  is  continuous  with  tiie  skin  on  each 
side,  lying  as  a  broad  plate.  If  only  a  snudl  part  of  the  canal  be  thus 
open,  the  condition  is  compatible  with  life  until  the  canal  becomes 
infected  or  until  so  nuich  fluid  is  drained  away  that  the  child  dies. 

2.  Incompii'te  Spina  Bifida,  livrc  there  is  failure  of  the  bony  struc- 
tures, but  the  skin  covers  the  protrusion  or  the  gap.  This  form  is 
classified  as  meningocele,  myelocele,  meningomyelocele,  syringo- 
myelocele, and  the  least  scriotis  form  known  as  spina  bifida  occulta. 
The  definition  of  these  fornix  may  be  left  with  surgical  text-books. 

Imperfect  Closure  of  the  Anterior  Body  Surface. — Tlie  embryo  is  at 
first  fiat,  spread  out  over  the  surface  of  the  ovum,  and  with  time  the 
edges  turve  in  to  meet,  forming  the  Ixnly  cavity.  For  some  time  this 
closure  does  not  take  place  and  the  viscera  actually  protrude,  as  does 
the  uUantois.  The  vinion  ultinuitel\  may  be  incomplete,  and  according 
to  the  region  in  which  failure  occurs,  we  have: 

1.  Sternal  Finsiire.-  If  t!ic  defect  of  closure  be  complete  the  thoracic 
viscera  protrude;  if  the  lungs  do  so,  they  cannot  expand,  and  birth 
is  death.     If  the  heart  alone  be  left  exposed,  ectopia  cordis  results. 

2.  Abdominal  Fissure-  Th'\s  causes  eventration,  the  protrusion  of 
the  viscera. 

3.  Hernia  of  the  Vmlilical  Cord.— An  incomplete  closure  of  the 
wall  at  the  umbilicus  may  result  in  the  proximal  part  of  the  cord  being 
enlarged  to  receive  a  portion  of  the  viscera.  A  condition  not  unlike 
this  arises  when  the  o!nphalonic>;cntcric  duct,  wliicli  originally  connects 
the  gut  and  the  yolk  sac,  remains  open. 


MONSTROSITIES  AND  ABNORMALITIES 


73 


4.  Vesicorjenital  Fmiire.— The  allantois  de\eIoi)s  from  the  hind  gut 
iiiul  runs  through  the  umhiUcal  region;  the  part  nearest  the  urogenital 
sinus  widens  into  tlie  bladder,  and  the  part  distal  to  this  closes,  and 
extends  as  a  cord  (urachus)  to  the  umbilicus.  The  urachus  may  fail 
to  close,  and  may  remain  as  a  tube;  the  bladder  may  fail  to  close, 
constituting  ectopia  vesicae.  Associated  or  not  with  this,  the  urethra 
may  fail  to  close,  constituting  epispadias. 

Fia.  27 


Development  of  the  face  of  the  human  embryo  (His):  A,  embryo  of  about  twenty-mne  day*. 
The  nasofrontal  plate  differentiating  into  processus  globulares,  toward  which  the  maxillary  proceswjs 
o(  first  Visceral  arch  are  extending;  B,  embryo  of  about  thirty-four  days;  the  globular,  lateral  frontal, 
and  maxillary  processes  are  in  Bpp<.8itioni  the  primitive  opening  is  now  hetlsr  defined;  C,  embryo 
of  about  the  eighth  week:  immediate  boundaries  of  mouth  are  more  definite  and  the  nasal  orifices 
are  partly  formed,  external  eat  appearing.  D.  embryo  at  end  of  second  month.    (Heisler.) 

Imperfect  Closure  of  the  Facial  Clefts.— The  accompanying  diagram 
will  remind  the  reader  of  the  different  fusions  that  occur,  with  obliter- 
ation of  clefts,  when  the  face  is  formed.  When  the  fusion  of  these 
apposing  surfaces  is  inhibited  totally  or  in  part,  we  have  produced  the 
Jeatures  of  an  earlier  developmental  stage.     Of  such  failures,  hareUp  in 


.WJH  -.«.,aMH:'.-HU1'-,'.^, 


74 


TIIK  CMSHS  (iF  DISHASE 


its  various  decrees,  with  the  acioiniKiiiyiiij,'  palatnl  iiiallormations,  is 
thf  oiif  of  most  clinical  interest.  In  its  sinii)icst  forin.  Iiarclip  atVects 
onlv  one  side  of  the  uitpcr  li|);  a  severer  form  is  tliat  in  wliieh,  m  ad<h- 
tioii,  there  is  a  hick  of  union  hetween  the  maxiUary  process  and  the 
intermaxillary  hone  extending  into  the  hard  or  the  hard  and  soft  palate 
cleft  palate  or  this  may  occur  on  hotli  >ides  (lniihlf  rhft  ixilatr;  or 
the  intermaxillary  hone  may  he  wanting  iiictlian  rlrft  palaic;  ijr  e  ler- 
nally,  the  cleft  may  extend  alonjr  the  side  of  the  nose  to  the  orhit. 

Imperfect  Closure  of  the  Branchial  Clefts.  In  the  ♦■i.ihryo  the  second 
and  lower  hranchial  clefts  pass  from  the  outside  into  what  ultimately 
will  he  the  pharynx.  If  one  of  these  do  not  close  at  all,  a  complete 
fistula  remains;  if  it  close  at  the  end,  a  simis  is  made,  and  if  it  close 
at  hoth  ends  a  cyst;  if  the  cyst  he  formed  from  the  i)art  of  the  cleft 
nearer  the  skin,  its  epithelial  lining  is  stiiiamous,  if  from  the  pliar\  igeal 
end,  columnar  and  even  ciliated.  The  Eustachian  tuhe  is  the  first 
of  these  clefts,  of  wliich  there  are  five;  the  second  is  the  one  which 
ofteuest  persists. 

Rectal  Malformations.  The  emhryonic  cloaca  in  the  course  ot  develop- 
ment is  transformed  into  certain  external  jreiiitalia  and  the  rectum. 
If  the  separation  hetween  the  ^'ciiital  and  the  rectal  parts  do  not  occur, 
we  have  the  condition  of  persistent  cloaca;  if  it  occur  (mly  partially, 
a  fistula  is  formed,  the  cavity  of  the  rectum  commnnicatinj;  with  some 
l)art  of  the  n^'nito-urinary  tract,  such  as  the  vagina,  the  bladder  or 
the  urethra.  Also,  the  septum  between  the  hind  fiut  and  the  outside 
may  not  he  broken  dow  n,  and  the  condition  of  atresia  ani  or  imperf(  rate 
anus  may  result.  There  are  various  grades  of  this,  according  to  the 
distance  from  the  surface  at  which  the  end  of  the  hind-gut  lies. 

Hermaphroditism.  The  matrix  tissue  {avlaijc)  of  the  genitalia 
remains  the  same  in  the  two  sexes  up  to  the  fifth  week,  and  alike  struc- 
tures b(>come  transformed  into  the  apparently  widely  differing  (frgans 
found  in  the  two  sexes.  Kach  part  of  the  male  tract  has  thus  an  analogue 
ill  the  female.  It  is  not  so  strange  that  cases  of  blended  sex  should 
occur,  as  that  they  shouhl  occur  so  rarely. 

True  IlermaphriKlitiwi.-  This  is  very  rare;  there  may  be  an  ovary 
on  one  side  and  a  testis  on  the  other,  or  both  on  one  side,  and  either 
or  neither  on  the  other,  «r  finally,  both  on  ea<'h  side.  The  secondary 
sexual  characters  (the  conformation  of  the  body  and  its  parts;  are  mixed. 
Falte  lIi-rmniilinxlitiKm.  This  is  far  more  common  than  the  former. 
In  it  the  genitalia  are  actually  of  one  or  the  other  type,  but  the  second- 
ary characters  are  those  of  the  sex  other  than  that  to  which  the 
genitalia  belong.  The  male  individual  with  feminine  characteristics 
is  the  more  common  of  these  (pseudohermaphrodismus  masculinus). 


POST-NATAL    ACQUIREMENT   OF   DISEASE 

Classification  of  Causes.    The  <aiises  of  disease  acquired  after  birth 
are  necessarih    external.     The  environment  may  be  altered  so  as  to 


rOST'XATAL  ACQUIREMENT  OF  DtSE.M^E 


75 


(•aii>f  disease,  or  injurious  substances,  living  or  dead,  may  he  introduced 
into  the  system.     The  agents  which  thus  prwhice  disease  are: 

1.  Mechanical -in(hicing  "trauma." 

2.  Physical     under  which  can  he  inchided: 

(a)  .Mterations  in  tlie  pressure  of  the  atmosjjhere,  inchiding  !)oth 
diminution  and  increase.  •     ,    ■■        t     i 

ill)  .\lterations  iti  temperature,  local  and  general,  indudmg  Ixtth 
heightened  and  lowered  temperature. 

{(•}  Ktfects  of  electricity,  hoth  atmospheric  and  induced. 

id)  Kffects  of  light  and  of  other  forms  of  radiant  energy. 

{(')  Ktfects  of  soil  and  climate. 

(/)  Sociological  etl'ects,  hahitation.  clothing,  dwelling,  occupation, 
101(1  other  environmental  conditions. 

;{.  Chemical  Causes  -  under  which,  hesides  («)  the  gross  effects  ot 
caustic  and  other  agents  ui)on  the  tissues,  we  should  include  (6)  the 
main  effects  of  vitiation  of  the  atmosphere  hy  various  gases,  and  (c) 
the  main  deleterious  effects  of  imi)roper  food,  as  again,  to  some  extent, 
the  deleterious  effects  of  certain  occupations. 

4.  Parasitic-   under  which  heading  are  to  he  included  the  deleterious 

effects  of: 

(«)  Mimite  vegetable  parasites-  bacteria  and  fungi. 

{!>)  Minute  animal  parasites-  sporozoa,  amcehip,  etc. 

ic)  The  larger  animal  parasites,  including  worms  (cestodes,  trema- 
todes,  nematodes)  and  arthropods  (arachnids  and  insects). 

As  one  reads  the  foregoing  table,  he  will  he  conscious  that  many 
of  the  agents  nieiitione<l  are  things  not  in  themselves  hurtful;  some  are 
even  therapeutic  agents  of  definite  value;  it  depends  upon  the  degree 
with  which  a  physical  or  chemical  agent  aifccts  the  tissues,  whether 
the  result  will  be  physiological  or  pathological. 

Mechanical  Causes  of  Disease.  Mechanical  cau.ses  of  disease  are: 

1.  ('oncussion. 

2.  Puncture,  with  which  may  be  included  the  effects  of  projectiles 
under  high  velocity. 

;>.  Section. 

4.  Contusion,  with  which  may  be  included  lacerations  and  teanng. 

5.  Compression. 
(1.  Distension. 

7.  Atmospheric  pressure  . 

1.  Concussion. -This  is  the  effect  produced  upon  a  s(>ft,  fliud  or 
Minifluid  body  by  the  momentary  application  of  force;  familiar  examples 
ire  l)lows  ui)on  the  brain,  or  ui)on  hollow  viscera  with  gaseous  or  fluid 
contents,  such  as  the  lung,  the  hliulder.  or  the  stomach.  The  brain 
1^  a  soft  substance  lying  in  a  bath  of  ffuid;  if  a  blow  of  sufficient  force 
I.e  struck  upon  the  skull,  without  fracturing  it,  the  brain  may  be 
iamaged  hy  being  proi>elled  against  the  opposite  side  of  the  skull, 
inasmuch  as,  being (ienser  than  the  iiiiid  In  ^^hich  it  lies,  it  takes  mure 
momentum  fiom  the  applied  blow  than  does  the  surrounding  me<i:um. 


76 


Till':  CAUSES  (IF  DISEASE 


ir 


The  small  hemorrhages  that  ai.pear  in  the  l.ra.n  are  not  necessarily 
the  result  cf  a  .lireet  l.low,  hut  of  the  shaking-asunder  action  applied 
bv  the  brain  bcinK  sud.lenly  brought  up  against  an  uny. tiding  surface. 
A  similar  result  is  seen  in  the  case  of  soft  tissues  bordering  upon  a  cavity 
containing  fluid  or  air;  a  blow  may  be  struck  upim  the  thorax,  and 
imnarted  to  the  lung;  the  part  of  the  lung  nearest  is  set  in  motion  away 
from  the  blow,  and  the  air  within  not  being  set  in  motion  with  as  much 
velocity,  the  conflict  of  two  degrees  of  force  acting  upon  the  tissue 
tears  it  Thus  is  to  be  explained  the  rupture  of  a  full  viscus  such  as 
the  urinarv  or  gall-!)ladder  r)r  the  intestine.  Inseparable  from  the 
conception' of  concussion  is  the  idea  of  molecular,  if  not  visible,  change 
in  the  tissues  affected. 

"  Puncture.-  A  stab  wound  is  a  familiar  example.  Ihe  damage 
mav  be  wrought  in  various  ways;  there  is  a  certain  destruction  of 
tissue  in  the  i)ath  of  the  blade;  there  may  be  great  damage  done  l)y 
the  weapon  piercing  a  large  artery  or  an  important  ner%  e  trunk;  bacteria 
mav  be  introduced  into  the  tissues  by  the  instrument,  or  from  a  hollow 
viscus  opened  up,  or  along  the  track  of  the  blade  from  the  air.  ihe 
puncture  of  tissues  by  projectiles  is  to  be  considered  here;  generally 
speaking,  the  higher  the  velocity  the  more  a  bullet  wound  approxi- 
mates to  a  "puncture",  with  low  velocity  the  character  of  the  wound 
is  more  of  the  nature  of  a  contusion.  It  will  be  obvious  to  the  reader 
that  in  discussing  these  mechanical  causes,  one  can  rarely  adduce 
examples  that  are  purelv  of  one  character;  with  a  punctured  wound 
there  mav  be  contusion,  and  nearby  tissues  may  be  compressed  against 
other  moVe  solid  tissues;  and  with  projectile  wounds  there  will  often 

be  concussion.  ,         t    •  i 

•,l  Section.— This  consists  in  the  cutting  asunder  of  tissues  by  an 
edged  instrument,  and  as  it  occurs  surgically,  entails  a  minimum  of 
etl'ect  upon  tissues  other  than  those  cells  actually  injured. 

4  Contusion.  DillVring  from  the  condition  of  concussion,  we  have 
here  the  effect  of  force  api)lied  directly  to  the  tissue  concerned,  forcing 
cells  asunder  from  cells.  The  disintegration  may  be  slight  as  in  con- 
tusion, where,  it  is  to  be  noted,  the  resulting  hemorrhage  is  mainly 
responsible  for  the  visible  signs;  or  more  sev.  c,  as  in  laceration,  or 
separation  of  one  part  from  the  rest  may  be  brought  about.  In  this 
form  of  lesion,  also,  the  injury  may  afford  opportunity  for  the  intro- 
duction of  bacteria  from  without  or  from  within.  ,      „     i 

5.  Compression.- Compression  tends  to  affect  rather  the  fluid  part 
of  the  tissues  than  the  solid,  and  we  thus  search  for  its  effects  in  changes 
in  the  nutrition  of  the  part;  C(mipresbion  made  by  the  weight  of  the 
bodv  when  blood  force  is  low  may  so  empty  the  capillaries  that  the 
tissues  are  ill-nourished,  and  a  bedsore  is  produced.  In  the  part  be\ond 
a  tight  ban.lage,  \he  stagnation  of  the  body  flui;ls  ina.\  induce  necrosis, 
and  the  tissues  actually  compressed  are  even  move  li.-sble  to  sufTer, 
The  effect  of  the  gradual  pressure  exerted  by  tumors  upon  neighboring 
organs  causing  poor  nutrition  in  them  is  well  known. 


POST-NATAL  ACQUIREMENT  OF  DISEASE 


77 


0.  Distention.-  Tlu-  principle  here  is  the  same  as  in  the  last  case; 
a  familiar  example  is  the  destruction  of  renal  tissue  in  hydronephrosis, 
where  the  increasing  urine  acts  as  the  disteiuling  force,  until  the  kidney 
becomes  a  large  thin-walled  cyst. 

7.  Atmospheric  Pressure.— Differences  in  the  tension  of  gases  in 
atmospheric  air  bring  about  changes  in  the  tension  of  gases  in  the 
blood  and  the  tissues.  If  the  atmosi)here  be  much  rarefied,  the  amount 
of  oxygen  taken  up  is  so  reduced  that  asphyxia  suiwrvenes.  Where 
the  atmospheric  pres:;iire  is  greatly  increased,  as  in  caissons,  there  is 
»  greatly  increased  amount  of  air  taken  up.  As  in  a  srola-water  bottle 
the  greater  the  atmos])lieric  pressiire  to  which  a  fluid  is  subjected  the 
greater  the  amount  of  gas  that  can  become  dissolved  in  it.  Remove  the 
cork  and  so  remove  the  pressure  and  the  excess  gas  becomes  liberated. 
This  increased  absorption  at  the  moment  does  no  special  harm,  but 
when  the  stibject  is  exposed  to  i  rdinary  atmospheric  pressure,  much 
of  the  nitrogen  so  taken  up  is  suddenly  liberated  in  the  form  of  dis- 
crete bubbles  which  may  mechanically  interfere  with  the  circulation 
in  the  capillaries.  The  oxygei.  of  the  air,  it  may  be  added,  has  become 
fixed  in  the  tissues. 

Physical  Causes  of  Disease.— Temperature. — By  reason  of  a  very 
responsive  heat-regulating  apparatus,  the  human  bmly  can  stand  expo- 
sure to  great  extremes  of  temperature,  from  100°  F.  below  freezing 
point  to  50°  F.  above  the  boiling  point  of  water.  Protoplasm  will 
freeze  at  the  one,  and  coagulate  nt  the  other;  but  the  body  is  protected 
in  the  case  of  cold  by  a  layer  of  warmed  air,  and  in  the  case  of  heat  by 
a  layer  of  air  cooled  by  the  evaporation  of  moisture  given  off  on  the 
surface.  If  the  air  be  so  moist  that  this  evaporation  cannot  occur, 
the  high  temperature  at  once  becomes  effective  upon  the  bmly  cells 
and,  therefore,  dangerous.  The  dangerous  effects  of  heat  and  cold 
are  manifested  in  local  change,  which  may  be  called  primary,  and  in 
certain  subsidiary  changes  affecting  the  whole  system  which  are 
secondary.  These  secondary  changes  are  remarkably  similar  in  the 
case  of  heat  and  cold.  Ff)lio\vin>r  the  initial  paralysis  of  the  vessels 
which  are  the  Iieat-regtilatii.g  mechanism,  the  vitality  of  the  cells 
is  arrested,  and  they  miiy  die.  or  at  the  best  may  throw  into  the 
circulation  deleterious  materials;  in  addition  the  sensory  nerves  of 
the  part  are  profoundly  irritated. 

It  is  thus  evident  that  while  heat  or  cold  may  cause  death,  yet  short 

this  the  effects  are  primary  and  secondary;  while  the  disease-causing 
.!  -nt  operates,  the  primary  effects  are  produced,  and  after  it  ceases 
to  operate,  we  ha\c  yet  to  reckon  with  a  train  of  secondary  effects. 
Here  exists  the  ditierence  between  physical  and  parasitic  causes  of 
disease;  in  the  latter  we  have  the  continued  effect  of  a  constantly 
present  agent,  while  in  the  former,  we  ha^■e  to  meet  the  after-effects  of 
a  temporarily  applied  diseasf^-cnnsing  agent. 

Light  and  Radiant  Energy. — The  most  definite  evidence  that  radiant 
energy  can  cause  disease  is  connected  with  cases  where  the  tissues  are 


78 


rut:  ctrNKN  '"•'  /j/.'^a'-^'S'' 


) 


..,v,,t..,l  hv  tlu-  .r-rav  s  n>,.l  ra.li.nn  ...«anati..ns      It  l.as  lurn  •-tunatod 

a     .     M-  ..f  ra.lin.n  r.nh\  U  .•..ll..t...l  ...  on.,  mass,  inen  > 
t;    wi^;^..  ;;  .■.-rtai,.  .Usta.....  ..f  it  woul.    .aus.  '^;;;  ;•  -I  „  '^-, 

""•'  i;:^'";"!;  r/ 1 '  ^  "m '  ::i":,.s  ti. .......  ....tnu  a,...  ..f  ti,. 

Zt::.:z.;::^^\':^  ■... .iti....  .„.-.  ,.r..,.r  ...s  ..r 

ti  n  V.1  s^^^^^^^^^^^  its  .•o.nl.inati..,,  with  .rrta...  tm,.u-nt  aco.n- 

;;;:;;.'in;';:S;if ;  i.  as  i.npnre  air.  .l..  i..  ti,,..  ,.nKl.u.  .ld.t.nous 

'■'S::tS''l  '  i"'a-S^;S-ult  to  .ive  .nuch  .lofinite  infor.natio.. 

.,ho  rS  'W.     ..f  <-I.;tricity  upon  the  tissues      The  ertn'ts  of    he 

f ..      ...rr  M.t  -.re  .litlVrent  fn.m  those  of  the  alternate;  it  seems  that 

^,, M, ,  1  fr„M,  .■l,«ri,i.v  tl«-  »„rst  tl,i„«  th,.t  .■«..  Iia,.|.™  t,.  thv  |»t  .■■,t 

i         I.     .  1.1 1..-  .'■.."i.-.i  ..II  t..  ■■'  l...»i.i'»l-    .I;"/""'/"-/;"-" ";" 

;;:;;;:r,:  ;';r ';"  ^m. ;  i  -"it..  '*,  ,i,m.' .vv^-  i.i«i.,  ,....e...ia. 

"■„,"!;■  |.™.l  .l,r„„t.h  .!.<■  i;.l...a1.  l..«l.v  «i.l'."«  '"J'">-  "I'I"'"SI'  '*»» 

..(•tion  ..f  a  caustie.  or  ot  :'.  more  n.<hre<t  effect  In    Ahieh  the  cells, 
a  tCg       ..t  .h>stro>e.l.  have  tlu-ir  functions  .hstur he.l      Any  snl< 
li      r;.r  .as  which  is  capal.le  of  heing  incorporate.!  with  the  ho.l> 
Zls.  an.i  thercl.v  conun,  to  a.t  .leleteri.,usly  upon  tl,e  cell  substance. 
,nav  Rive  rise  to  morl.i.l  changes,  and  thus  he  a  pois.m 

Poteons  \Ve  Iku-  jn>t  stated  that  chenucal  sul.stanees  that  ac 
.U-UneSsh  mav  .lo  I,  either  as  caustics,  that  is.  as  substances  that 
■^TZm  M\.  l.y  .lirect  contact^  with  them,  or  as  .n  ox.ca^|  s^ 
that  is,  as  .ubstan.T>  M.at  act  harmfully  >,:„.„  ctu.  by  rca».m  of  l>emg 
...rp^rated  w  h  bouy  flui.ls  and  exertmg  the.r  ''iflf^.^;'!'""  ^^'^^ 
any  Aerc  i.i  the  luuly,  even  at  a  distance  from  the  point  of  first  contact. 


POST  \.\TM.  ArQt'llit.MKST  <>F   ni<h:.\^F. 


79 


Intoxication  is  tin-  prixrss  l»\  wliidi  such  iiulinrt  act  ii  i-  hrir.i«lit  iiltuiit. 
'I'lic  term  poison  is  so  wide,  tiint  it  iiiclii<U's  not  only  Mil)staiiccs  that 
wc  ((iiisiilcr  noxious  in  tlicir  very  nature,  l>.  t  also  siil>stancc->  in  tlictn- 
mIvcs  harniU'ss  whicli  li>  reason  of  their  anionnt  can  interfere  with 
the  orderly  and  i)roi)er  perfomiance  of  the  duties  of  the  cell.  .\  poison 
i,  not  onl\  that  which  imlucc-  molecular  distnrhance  and  disonlerly 
clu-niical  change  in  the  cell,  hut  also  that  which  interferes  with  or 
inhihits  the  normal  molec\ilar  ihanjtes  in  the  protoplasm.  .\n  example 
of  this  poisonous  action  hy  a  suhstanee  in  itself  no  poison,  is  found 
in  the  case  of  water,  which  is  essential  to  existence,  and  constitutes 
7(1  per  cent,  of  the  IxMly  weight;  if  it  he  introduced  into  the  tissues 
ahovo  a  certain  amount  (tiO  c.c.  per  kilo  of  l.ody  weij;ht)  it  may  kill. 
This   will    indicate    how   wide  a  meaning  w    liestow    upon    the  term 

piiiniin.  .  . 

I'oisons  may  he  at  once  divided  into  two  jjroups,  exogenous,  arisuij; 
outside  the  .system,  and  endogenous,  arising'  wifliin.  In  dchninj;  what 
is  exojrenous  and  what  is  endogenous,  we  must  he  careful;  fo<Ml  material 
in  the  alimentary  canal  has  not  yet  heeome  a  part  of  the  or^ani>m, 
and  is  as  yet  external  to  the  lining  epithelium  of  the  hody;  yet  many 
wroii>;ly  sjjeak  of  the  absorption  of  decomi)ositio!i  |)roduets  of  it  as 
luito-iiitnxication,^  as  if  such  poisons  were  endop-nous  instead()f  hein^, 
as  they  are,  exofjenous.  The  strict  and  useful  definition  of  the  two 
terms  must  he  held  to  he:  endoj;enous  poisons  are  substances  actually 
deri\»'d  from  the  cells;  exogenous  those  set  uj)  hy  suhstanees  forei>,Mi 
to  the  cells.  Thi:^  latter  will  include  even  the  products  of  haeteria  in 
the  tissues. 

The  intoxications  then  may  he  j,'rouiM'd  as  follows: 

I.  Elxogenous  Intoxications. 

1.  Xiin-imranitir.'  Intoxications  due  to  the  actions  of  poisons  not 
produced  in  association  with  the  organism,  whici  sjain  an  entrance 
into  the  system  throujili  the  .skin,  di^restive,  resj)iratory.  or  urinary 
tracts. 

2.  I'arunitic. —  in)  Paranitlr  prupcr,  <lue  to  the  intriMiuction  into, 
and  >;rowth  within  the  tissues  of  parasites  of  vari-us  orders,  animal 
,ind  ve>;etahle,  which,  arrowing,  give  rise  to  to.vic  sii!)-tances. 

[h)  Saimiphytic,  due  to  the  growth  of  parasit(  nf  various  orders 
on  one  or  other  surface  communicati'ig  with  the  exteri<)r  of  the  organ- 
i-ni,  the  products  of  growth  l)ecoming  absorbed  and  diffused  into  the 
tissues. 

n.  Endogenous    Intoxications.     Of     pure     ty|)e;     auto-intoxicatu)ns 

pro])er. 

!.  Internal  xrrn'tDrt/,  intoxications  due  to  altered  intenuil  secretions 
(.11  the  part  of  the  body  cells  affecting  (ti)  the  secretory  cells  and  tissues 
tlieniselves.  and  (h)  the  other  tissues  of  the  organism,  through  diffusiim 
of  the  altered  products  of  cell  activity. 

>  (irr<>c,  self. 


iCP 


m 


•  CMSKS  OF   DISEASE 


gQ  Tin:  CM  Sh.-^  «'/■    ""- 


unit 
exert  1 1011 


EXOGENOI 


INTOXICATIONS     N0N-PAEA81T1C 


.    ■       tl...  l,n,lv  or  ii'  M.rJ)e«l  l>y  it  act   (1) 
Foreign       i.^ta.ur>  vntvnu,  tu      o  b      r  ^^.^ 

locally,  at , h-  vf'^  f  'X^/!  Hw!.;;^  ^.generative  or  necrot^; 

sufliceiit  tii.ieela  )>e>,  tliir.  i^  t       "'  'l,.,,,..:,,,,       If  u  poison  like 

;i',.  ,„„> ,,..  f...n.;«" ,:;:;;  'r,;  ::.:-:;.  .1.- .™!-»'  *-«; 
:;;;';;,■  i:;,:;:V.i:4ii- .''"'«»'  '■«-" """ '"" 

•"ivSnrmav  hri„„  .1..,,.  O^ir  „e„en.l  eff...»  W.  >l,c  t..llo.i..«  »«>»: 

of  function.  ,;,•:.  v   foUowedhv  <lisintegration. 

:>,.  By  increase  of  (rll  a>  "^^/>;  J'  ;;''',,,;  ^.^,^1,1  he  merely  to  rata- 
To  classify  the  po.suns  un.  er  s  .      i^^^^Z  l^ne  selective  etfeets 

loguethein;  it  is  better  tojah^^^^^^^^^^^^  ^,,^^  ^,  ,         , 

!;;:::;;:;r;;;r:;^^;e';:::i^.:*s  ..e  ...rence  to  ti.  tr^^ies  of 

on  account  of  its  ''^''"-^^X  fore        at  .iitlerenees  according 

aHVcted  by  poisons  ami  ^^J^"'\'  f  ^J^     ,.' T,,,  ..f  tlie  high  degree  .>f 
to  the  intensity  of  the  dose.     15>   M  ^^.^^^^,  ^.        ,. 

''-•'•'••"""'■'V'  ^'rr^tr^lli"- us  CO  reT  n^^        for  severe  cerebral 

;i;:;s;;;:;;S:;in;;!;)^;nS  u;:ip  ^^  -- »» -^>—  ^^-^  ^^^-^ 

little  or  no  ettVct  on  lower  animals.  prouned  as  follows: 

"^Wisons  acting  upon  tl-  --- ^^^  ^^^I^SX.  ..  ...  hydro- 

1.  Th<.>e  <ausing  arrest  ot  f^'f^l'^.^^^^^^-'^^  ^^^  sedatives, 
cyanic  a<-i.l;  -'0  --ot  >"nued.at.>^  r.  ,    l^P^^^j;^,,^^^.,,,  i,,-  .nminution 

o   Those  causing  increase  ot  cell  activiiv    i 

of  "function,  c.  ,..  alc.hol.  ''I'l^'l^f^J:  »  7;,^;,  ^  ^j  bv  exhaustion  an,l 
3.  Tho^  causing  increase  o^  ac^n  t ^.    ^  -  ^  ^^^.  ^^^^.^^  ^^^.  _ 

at  times  disuuegr:.  urn-      f..sr<l'"e  ^^^^^^  ^^^^^^  particular 

It  is  notable,  also,  that  "'•'">         "  ,,^.,,  test  activity, 

parts  of  the  nervous  system  as  tht  sitts  ot  inc      « 

•'7^n;h:^cm'b:^Ventres:    Hypnotic,  carbon  dioxi.le. 
of  potassium  and  ammonium. 


EXncKSC'is  is'Toxr  \Tin\s   \n\-r\i;  \sitk' 


si 


I.  l'cri|>luTiil   luTvi 


F.fluT,  (  hldrcforni.  <arli('Ti  dioxide  (;ili>riiiK 


U-ctr..in..l.ility),   dii.litli.rin    »«.xiii.  iiikI.    po^sil.lv,  U-ikI    mid    alrohol 


.').  N»TV«>  ttTininatioiir- 


Cirart',  rncaiiu-,  vrratrinc.  iiicdtiiu- 


(■((iifroiitiMl  l)v    tin-  iiiH'stit.ii   liow  this  seU'ctiv 


tinii   is  hroiiKlit 


that  it  is  siijrjjcstivr  that  flu-  liypiiotics,  an  a  Kroup 

iui>'l»"i"i  fats  and  lipoid  ^nhstaiui-s,  and  tin-  ahuiidanc'  ..f  <tT«'l)r. 


alioiit,  \\v  may  say 


arr  sol 
sidi's, 


lialiiis,t't<-.  (\vlii<li  arc  Hpuidsi  in  tin-  nt-rvoiis  svstrin,  s.rnis  t 


<fp-  •     1        1  r    ■ 

i.cc.mit  for  the  amount  taken  n|>  by  thi>  partunli'.r  class  of  »'•*>«'«' 

Poisons  Acting  on  the  Muscular  System.  Ai)art  from  the  .■IT-ets 
prodnee.1  ui)on  striated  nnis.le  hy  the  mnliation  of  the  nerves,  there 
yt  remain  some  poisons  whirl,  appear  to  ac*  directly  ii|M.n  the  muscle 
iell-  these  either  excite  inc-reased  contract  1  ■■  or  make  the  coiitrac- 
ti.m'  more  feehle.  Of  the  former,  the  IrrtUUve  examples  are  (lUMuno. 
catVeinc,  veratrine  (small  doses),  hypoxanthine,  and  creatine,  as  well 
as  the  toxins  (.f  the  MaciHiis  coli.  Of  inhibitiTe  poix.iis  may  he  men- 
tioned the  potassium  salts,  the  alkaline  earths,  and  copper. 

It  is  suppo-^ed,  too,  th.it  certain  jKHsons  pnHliicc  definite  effects 
upon  uiistriate.1  muscle,  aiul  it  i.  with  this  i.Ica  that  atropine  is  admin- 
i,tered  to  excite  peristalsis  1  ;  cases  of  so-called  "paraiytK-  distension 
.,f  the  intestines"  oc.MrriiiK  in  peritonitis;  mori)liiiie  appears  m  arrest 
pcristalsi-,  l.v  a  <lirect  action,  while  er^ot  is  considered  to  stimulate 
uiistriiH'd  muscle  to  coiitra<t.  .\drerialin  and  liariiim  chloride  seem  to 
caUM>  the  muscle  of  the  arterioles  to  contract.  These  points  still  retpiire 
(•um|)lete  verification.  ,,      ,  i 

Poisons  Acting  upon  the  Blood  Corpu8ci«,i.  I  lie  blcMxl  corpuscles 
arc  protecte.l  from  in  iv  injurii.us  substances  1.'.  t  ."  alteration  that 
Midi  Mil.stances  iinderp  n  the  i>rocess  of  heiii);al)M.  ;/'i.  '"it  it  injected 
directly  into  the  I)1o(m1  stream  these  arc  effective. 

1.  Hemolytics  inemodastics).— The  destructio. 
(.ir|)uscies  may  be  .rou^'ht  about  by  physiial  mea; 
the  tonicitv  of  the  plasma  by  the  injection  of  wate 
l.\  thawinj!'  Some  <lru>;s.  such  as  saponin,  abriii,  aii.l  ricin  are  effective, 
aiul  manv  Imcterial  toxins  and  animal  venoms.  .\lso  daiifjeroiis  to  the 
hodv  tliou^h  without  there  necessarily  beuiK  hemolysis,  are  those 
^tal'.lc  c(mibinatioiis  of  heim.jjiobin  with  carbon  numoxide,  carbon 
dioxide,  cvanojren,  and  the  cyanates  which  i)reveiit  the  pror-r  absori>- 
tioii  <.f  oxygen  and  carbon  <lioxi<le  in  the  normal  process  of  •--.piration, 
iiiid  so  cause  asphyxia. 

•>  Leukolytics.- There  af  some  poisons  which  can  cause  destruc- 
ri.m'  of  white  blood  corpus*  Ics,  but  one  must  be  careful  to  note  that 
l.ukoiH-nia  (lessened  mimlxr  ofleukocytes  in  the  circulating;  bloo<l>  .  ly 
not  be  <lue  ti>  destruction  <.f  leukocytes  so  much  as  to  altered  .listri  ;.;• 
tiun  in  the  IxmIv  at  large.  I'ancreatin  can,  however,  cause  tli.>ir  destru. 
;  i.,n,as  also  can  the  i)res.uce  of  bile  salts  in  excess.  \N  here  the  destruction 
<  im  be  recoguizetl,  it  is  cpiickly  followed  by  the  appearance  ot  a  leuko- 
.  >  tosis,  which  is,  again,  at  first  not  so  luucii  .lut-  lu  regeneration  as  tu 
redistribution. 
6 


|.;i;'        blood 
..  'i  ,is  alterir.g 
..eeziiig  or 


^ 


82 


THE  CAUSES  OF  DISEASE 


Poisons  Acting  en  the  Organs  of  Circulation.  I'oisous  may  affect 
(1)  the  heart.  ..r  (2)  the  vessels  jmrticuhirly  the  urtenoles,  or  0^)  the 
nerve  centres  that  control  the  canliac  mechanism;  it  is  extremely  diHi- 
cult  for  the  observer  to  know  which  of  these  is  being  acted  up  n  the 
most,  because  their  relationship  in  function  is  so  intimate. 

Poisons  Acting  upon  the  Heart.— It  has  been  (letermined,  however, 
that  certain  substances  such  as  digitalin,  digitalein,  digitoxin,  strophan- 
thin,  an<l  the  barium  salts  cause  stoppage  of  the  heart  in  systole,  whereas 
arsenic,  antimonv,  potash,  chloroform,  anrl  alcohol  in  sufficient  doses 
can  cause  stoppage  in  diastole- which  last  is  perhaps  the  reason  for 
the  occurrence  of  acute  dilatatio;.  of  the  heart  in  drunkards.  Ihe 
heart  whose  ventricle  stops  in  diastole  fails  not  because  of  inhibition, 
but  because  of  paralvsis  of  the  accelerator  nervous  mechanism. 

Poisons  Acting  upon  the  Vessels.- These  caus"  (1)  contraction  (>r 
(2)  dilatation,  bv  direct  action.  Ergot  and  ergotin  cause  contraction 
of  the  arterioles  by  direct  action,  apart  from  their  influence  upon  the 
heart.  Adrenin  iuid  barium  chloride  do  the  same.  Dilatation,  on 
the  other  hand,  is  directlv  i)roduced  by  the  nitrites,  chloral,  quinine, 
and  atropine  (small  doses).  It  is  a  strange  fact  that  some  of  the  drugs 
mentioned  liave  a  >elective  power  upon  the  vessels  of  certain  organs. 
Quinine  acts  especially  upon  the  spleen,  digitalein  upon  the  kidneys, 
nin\  1  nitrite  u|)on  the  superficial  facial  vessels  and  upon  the  respiratory 
tract.  Adrenin,  while  it  causes  the  vessels  of  most  organs  to  contract, 
when  applied  to  the  surface  of  the  i)ancreas  causes  vasodilatation. 

Poisons  Acting  upon  the  Digestive  System.— It  is  necessary  when 
examining  the  elVect  of  a  juiison  upon  the  digestive  tract  to  ascertain 
its  effect  when  introduced  into  the  digestive  channel,  (a)  with  the 
vagi  and  svmpathetics  intact,  and  {h)  with  t'.ie  same  divided,  and  also, 
when  iiitn)(luccd  snbcutaneously.  It  will  be  seen  that,  by  reason 
of  the  intricacN  of  the  mechanism,  the  possibilities  of  error  are  great. 
Apomonihine,  to  induce  eniesis,  must  be  injected  snbcutaneously, 
ipecacuanha  must  be  put  into  the  stomach  with  the  vagi  intact.  If 
the  vagi  are  cut,  even  large  doses  are  ineffective.  .Magnesium  sulphate 
introduced  into  the  blood  or  snbcutaneously  will  cause  only  moderately 
increase<l  peristalsis;  introduced  into  the  bowel  it  causes  abundant, 
watery  evacuations. 

Poisons  Acting  in  the  Mouth.  AH  the  poisons  which  cause  increase 
or  diininntiuii  of  salivary  >('crction  rccpiire  first  to  be  absorbed,  and 
their  action  is  thus  reflex. 

Poisons  Acting  upon  the  Stomach.  \'oiniting  is  a  process  in  which 
the  nervous  ^vstcin  is  dominant  whether  the  impulses  be  originated 
from  the  meiinlia  or  ui>on  the  nerve  enilings  in  the  stcmiach.  There 
are  many  irritiint  jHiisoiis  which  can  set  u]i  irregular  i)eristalsis,  con- 
traction, and  relaxation  of  the  .  toniach  walls. 

Poisons  Acting  upon  the  Intestine.— Diarrhea  is  tc)  be  recognized  as 
a  term  which  may  refer  to  two  distinct  processes.  These  are:  (1)  the 
premature  discharge  of  the  contents  of  the  small  intestine  without  due 


EXOdENOUS  IXTOXICA TlOXfi— NON-PARASITIC 


83 


alis(»ri)tioii  and  incMlificatioii,  and  (!')  tlif  discli.Tjje  of  excessive  secre- 
tion from  the  mucosa  of  tiie  intestine.  The  first  of  these  is  due  to 
increased  peristalsis  ("roton  oil  produc.-s  this  directly;  rhubarb  or 
senna  injected  into  the  veins  will  cause  it,  and  aloes  when  injected, 
only  when  there  is  a  free  flow  of  bile.  The  second  process,  the  increase 
of  secretion,  is  produced  by  the  saline  purgatives. 

Actual  lesions  of  the  intestinal  wall  are  pHnluced  l)y  poisons  in  two 
wa>s:  (1)  by  direct  effect,  and  (2)  in  the  process  of  being  eliminated 
nito  the  bowel  after  l)eing  absorbed  there  or  elsewhere.  The  former 
are  most  likely  to  be  situaie<l  in  the  upper  part  of  the  tract,  and,  in 
the  case  of  caustics,  at  narrow  places.  The  latter,  the  eliniinat'ive 
lesions,  may  occur  in  any  part  of  the  tube  where  the  secretory  struc- 
tures are  mnnerous.  Duodenal  ulcers,  as  they  are  observed  in  burns, 
may  be  of  this  nature;  the  so-called  uremic  ulcers  undoubtedly  are! 
Ulcerations  and  other  lesions  ;een  in  the  colon  after  the  ingestion  of 
corrosive  sublimate  may  be  reproduced  if  the  poison  be  intrwhiced 
by  otiicr  paths,  and  thus  are  definitely  due  to  elimination. 

Poisons  Acting  upon  the  Liver.— One  of  the  most  important,  if  not 
tlic  most  miportant,  of  the  functions  of  the  liver  is  to  stand  between 
the  toxins  of  the  alimentary  tract  and  the  body.  By  ics  site  at  the 
head  of  the  j)ortal  system  it  comes  in  contact  with,  neutralizes  or  elimi- 
nates the  toxins  that  load  the  portal  blood.  This  it  does  sometimes 
at  a  hcav\  cost  to  itself.  Nor  is  it  only  with  portal  blood  that  it  has 
to  dial,  for  sulphnidigotate  of  scMlium  introduced  into  the  circulation 
entered  the  bile  one  minute  later,  and  must  have  gone  in  directly  by 
t  ic  arterial  supply.  In  the  case  of  the  liver,  then,  we  are  dealing  with 
the  .'fleet  of  toxins  directly  upon  the  tissue.  The  various  poisons  with 
which  the  hver  has  specially  to  deal,  and  which  are,  therefore,  prone 
to  ciiiisc  damage  to  it,  may  be  groui)ed  as  follows: 

1.  Metals  aiul  metallic  salts,  i)hosi.horus,  arsenic,  lead,  mercury, 
jH"!  .upper.  After  ingestion,  upon  analysis,  these  substances  will 
!"•  I'inn.l  111  greater  quantity  in  the  liver  than  elsewhere;  and  as  they 
:ir.  .x.ret.d  ni  the  bile  they  are  in  i)art  again  absorbed  by  the  bowel, 
aiicl  .arrie.l  once  more  to  the  liver. 

-'.  TUv  t.)xi.-  products  of  .ligestion,  inrlol,  skatol,  and  the  toxins 
trom  Im.tenal  growth  in  the  bowel.  When  these  are  in  excess,  the 
iiur  (•.lis  cannot  handle  them,  an.l  the  overplus  goes  into  general 
' T'  'ilatioii,  t„  the  detriment  of  the  b.i.ly. 

'■'■  Tho  tf)xins  of  pathogenic  bacteria. '  It  is  one  of  the  most  frequent 
ot  ohMTvations  that  the  liver  suffers  in  acute  infecti.)ns,  either  sh.)w- 
n>-  .■loiwly  or  more  severe  degeneration,  or  even  actual  cell  death 
local  or  general  necrosis). 

1    The  pro.Iucts  of  .lestructi..n  ..f  the  red-bl.,...l  cells  (hemolvsis). 

t  iia.  iHrn  lonn.l  that  as  a  oiiscqiience  .)f  certain  t.)xemias  the'liver 

I"  <  oni.s  in.apable  of  dealing  with  the  excess  .)f  bl.).).l  pigment  given  to 

"  ■  ■md  althongh  the  original  t.ixemia  may  be  partly  to  blame,  the  excess 

'"  pi^Miunt  itsflt  api)ears  to  take  a  part  in  causing  the  damage. 


H 


g4  Tilt:  CMSES  OF  niSK\SK 

i.u-   viArtava   -T\\o   iriMUTiil    Statement   just 
Poisons  Acting  upon  the  K^Jney".     ['^^^^^         j,,^  ,„,„,  it,,,f 

nu^le.  that  the  <7'''[ ;;•'"'^^  "  >  /.  ..^t,  I  '  liver;  the  kulnevs  must 
suffer,  applies  f.  the  k..lne>>  as  t  '  ;^"  ";,  ^;^,^,„i,  ,ireulation; 
bear  t!.e  hrunt  of  th.-  toxu-  ^" '^*"'  ,;  '"J ,  f  Jj,,  ,i,.,r  are  equally 
certain  cf  the  n^ta^  ">-^-;;:,;  ,;,  ^,-  '^tWr  sul .t^nces.  sueh  as 

distinct  predilection  for  these  organs. 

EXOGENOUS  iNTOHCATIONS-PARASmC  CAUSES 

f  ,rw..M^.>  -ire-    (1)  mii-roparasites  of  vegetable 

Bactem  "«'»"=  J^  ,,^,,m  t.K.  small  t..  be  *,■„  bv  thi-  micnn 
Zl;i;,;;,.n:r  l,in;;;i;'  ".lal  c«xi,  ,h.  nnUke  b.*  an,l  the  sp.ral 

J  ,',„,,  i„.e  ,„„iia  .,;■  .;t-r;n'rr  ;,;;.r:r;e;s 

;:f  free- ,";.>, .bU.«„  -'"'"j;;,;;^-^  ti;  t  Tl        bin" 

H,         ,-..ur.r  ..t  tin,,.  b,v ai-bU.  ..f  t,.nnent,.,K  .be.n.     M  -t 

i,™„„'',„  ..f  all.  ,1..  ,«tla*.ni.-  ba.teria  |,r,.  n,e  «mm.  .nl~a,ue» 
that  .MTt  a  |...i»oiK.a.  a.  ti.ai i  "til"  bvniK  tlimi.-. 


MPH 


RxoGExnrs  intoxica tioxs—pa uasitic  cacses 


8- 


Ilavinj;  in  view  tliis  power  of  pnxlucin};  toxins,  Imctcria  are  divisible 
into  three  groups: 

1.  Tlie  non-toxic. 

2.  Those  oniiiiarily  ineapahle  of  miiltiplyinj;  within  the  tissues, 
hnt  j;rown  outside  the  b(Hly  capable  of  pnKlucin);  toxins  which,  if 
al)sorl)ed,  are  injurious.  Here  belong  many  saprophytic  and  putre- 
factive bacteria,  which  may  become  hnlged  in  wounds  and  set  up 
irritation  there,  and  may  give  oVl  for  absorption  their  tcxins,  without 
themselves  gaining  entr>  to  the  tissues.  Here  also  belong  some  of  the 
normal  inhabitants  of  the  intestine,  which,  in  excej-s,  may  give  ofT 
toxins  that  are  dangerous  to  the  host  if  absorbed.  Some  of  these  last, 
at  times,  are  converted  intr  members  of  the  following  group: 

li.  Bacteria  capable  r>f  growing  in  the  tissues  (and  giving  off  toxins) 
and  there  setting  up  infection.  From  the  foregoing  it  will  be  apparent 
that  a  bacterial  intori'ution  is  the  ccmdition  in  which  the  action  of 
the  products  only  (.:  bacterial  growth  is  considered;  while  an  infection 
is  that  condition  in  which  in  addition  to  the  intoxication,  the  bacteria 
themselves  are  in  the  tissues,  and  are  multiplying  there. 

Toxins. — The  term  toxin  is  used  somewhat  laxly  to  indicate  the 
jMiisons  which  owe  their  existence  to  the  bacteria;  but  this  does  not 
mean  that  they  are  necessarily  manufactured  by  the  bacteria.  An 
example  will  make  clearer  this  statement.  In  iliphtheria  a  highly 
toxic  allumose  is  found  abundantly  in  the  spleen  and  other  tissues, 
but  very  little  is  to  be  found  in  the  membrani  in  the  throat.  Th- 
membrane  is  toxic  enough,  it  is  true;  the  mode  of  hajjpening  is,  probably, 
that  an  enzyme  manufactured  by  the  bacilli,  and  present  in  the  mem- 
l>rane,  diffuses  out  and  acts  upon  proteid  substances,  which  l)ecome 
(■(Hiverte<l  into  toxic  albumoses;  ihese  it  is  which  constitute  the  poisons 
of  the  disease.  This  idea  we  would  emphasize,  viz.,  that  in  many 
cases  at  least,  the  ba(terial  product  is  an  enzyme  which  is  not  itself 
the  real  toxin,  but  by  acting  on  proteid  materials  prcMluces  out  of  them 
t  lu'  active  toxic  substances.  It  is  only  nght  to  say  that  this  view  is  not 
yvX  universally  accepted,  but  there  is  much  reasonableness  in  it.  Like 
( ii/.\  ines,  very  small  quantities  of  the  primary  toxin  sufSce  to  prcnluce 
iiiitxiinal  disturl)ances;  action  is  not  immediate  ami  is<umulative.  The 
jiriniary  toxins,  tt)o,  are  precipitateil  like  enzymes,  are  thermolabile,  are 

I  ndercd  inert  by  temperatures  of  ")(>°  to  (iO°  '.,  and  they  diffuse  slowly. 
Tlic  discharge  of  toxin  in  the  active  metabolism  of  some  pathogenic 
I'Hftcria  is  very  small  in  amount.  If  cultivated  outside  the  bcKiy, 
ili'M'  organisms  set  free  but  little  toxic  niateriai;  but  if  the  bacterial 
iiiilits  are  broken  up.  toxin  is  .set  free  in  adequate  amount.  Such 
I'xiiis  arc  evidently  truly  intracellular,  and  are  directly  comparable 
111  ii.tracclluhir  enzymes  that  have  l)ccn  discovered  in  tissue  cells.  We 
tiiii>   divide  the    i)athogenic   bactpria    into    (I)   the   endotoxic,    such 

"L';inisnis  as  those  of  typhoid,  tul>ercuIosis,  cholera,  etc.,  and  (2)  the 
rtctotoric  under  which  are  included  the  b.  diphtherite,  the  b.  tetani, 
I'.  |>yocyaneus,  b.  botulinus  of  meat  poisfming,  etc. 


gg  Tin:  CAUSES  of  disease 

The  Nonnal  Defences  of  the  Or.ranism.^-It  b  ^^J^^ 

the  ways  in  wlm-h  bact.-r  a  pun  I"''*"!;";  /    \'  .^.'^m     T»'^  h"»'^" 
„osses;ed  hy  the  lunly  ot  '^^''-'/l-^  ^^i*    f.'      ur,n"e  of  which  is  to 
„Kly  has  a  continuous  external  ^^l"'^'^^^  „„,,.  the  skin,  but 
prevent  t^.e  -trance  ....|..n.....--^  ^^  ,^^,,^^^ 

alsothehnn.gofeve^     a  -^^^^^^^  l^^^^^^^^  „f  eovenng  m 

vipon  the  surface.     Ihe  ..nl>   Dr  ..k  .        ^  ^|     pallopian  tube  to 

the  human  bmly  is  in  the  case  ot  ^ '«  "^^^'^.^  j^  ,„  ,,eeplv  situated, 
the  peritoneum;  this  has  s..  hne  a  ^'-^T'"  yet  this  opening  has 
that  it  is,  to  all  irtents  and  purpo.es   clo  ed      Yet  t  ^^^     ^.^^^^ 

proved,  even  in  «l>P^'-^"\,!?f;;';  1,'  '  reUptU^/the  human  body 
peritonitis  being  set  xip.,  ^))  '\,\^ou  sWe,  ^  he  skin,  in  the  mouth, 
is  a  "close  corporation.      Un  the  ouisiut ,  ^^^^^^^ 

in  the  upper  air  passages  ">  '- "'^  "^^^  :\  "e  Tuccefd  in  getting 
are  cuntless  billions  ot  ''>;;•  ™;,,^;J/j  d..  so  constantly,  but 

their  tenure  of  existence  within  is  a  very  -hort  one. 

The  mechanisms  referred  to  are  these.  constantly 

1.  Surface  Washing.-  Ihe  bacteria  on  tiit  sk  n  j^  jj^d 

removed  by  washing  or  by  '-^-'''.f":',^^*;^^  \c^l  g^^^^  kills 

r"  ''>  f  fz^^  s:  muc  iu  -uu^^       ^r- 

the  majority  of  tliem.     l lie  mucus  i"      ,,•..,,  |.„„t    while    t  catches 
the  alimentary  tract,  and  the  J™^'^'';,„^J  " ;'  ,,  '^^^^^^^  ro  their 

times  are  almost,  it  not  quite,  f  "'f-  ,  ^  „  „f  t,,,  stomach  or 
that  most  peritoneal  l"'- .""^  J";';"*.  ''^i^^^^S^ 

the  upper  part  of  the  intestine  are  U  >>  ^  "-^  \  ,  \  ,>  killing  of  many 
„f  the  ileum  or  colon,  which  is  ^'''\''^\7^.  "^.  „!,,,  '"vit^  diminu- 
and  the  attenuation  of  other  »;«^'^\'"^'  /      .^^.'^^^^  this  no 

tion  or  absence  of  the  hydrochlonc.  XtT^l^^ak  pass  down 

^2^rbowcl,whereth.rnu.lti^tj^nia>;^^ 
of  cours.',  enunnons  m.mber>  .f  '"i^,^"'^;;    ''^^  •„,  ^he  intestines 
As  an  indication  ot  the  extent  "'»,;«    ^^^'^^  ,,,^.  .,ried   feces 
it  may  be  said  that  on   an   f  •■"^^-;^  ',',^;' !;,,,'      d  of  bacterial 

bacteria  dis.^harged  rrn,:»m  ,<S.'.>/  grams,  orotlu  r%M>t ,ostr  - 


EXOGENOUS  INTOXICATIONS— PARASITIC  CAUSES  87 


li.  Physical  Hindrance  in  the  Respiratory  Tract.— If  air  roiitaiiiiiig 
(lust  and  otluT  particles  impiiijrcs  upon   a  moist  surface,  the   solid 
particles  a.lliere  to  it;  the  breath  that  is  drawn  through  the  nose, 
l)assin)j  through  the  devious  maze  of  the  turbinate  bones  and  reflected 
by  till-  pharyngeal  surface  is  very  thoroughly  purified  before  it  reaches 
the  trachea,  and   in   health  the  expired  air  is  again   relatively  free 
from  orgif  ■  ms.    It  has  been  pointed  out  that  the  varying  caliber 
of  the  larynx  and  trachea  inchices  a  spiral  motion  of  the  inhale<|  air, 
thus  bringing  each  successive  portion  of  it  in  contact  with  the  lining 
nnicosa,  so  additionally  ensuring  the  arrest  of  solid  particles.    The 
particles  that  Uulge  on  the  surfaces  are  either  expelled  again  with  the 
nasal  mucus  in  blowing  the  nose  or  by  expectoration,  or  they  are 
swallowed,  or,  in  the  case  of  a  small  percentage  of  them,  absorbed 
into  the  tissues  that  surround  the  upi)er  respiratory  tract.     These 
particles  are  of  many  sorts— bacteria,  dust,  smoke,  and  so  on.    Among 
them  there  are  sure  to  be  many  that  are  a  menace  to  the  individual, 
and  it  is  for  the  disposal  of  these,  in  part,  that  nature  has  provided 
so  large  a  mass  of  lymph  tissue  in  the  neighborhood  of  the  upper  respira- 
tory tract.    Between  the  level  of  the  roof  of  the  pharynx  and  the  top 
(it  t!ie  sternum  there  are  very  numerous  collections  of  lymph  nodes, 
.  aryiiiK  in  importance  from  the  tor.sils  to  the  smallest  cervical  nodes, 
all  togither  constituting  a  large  amount  of  tissue.    Just  as  a  country 
places  most  garrisons  near  the  frontier  that  is  most  open  to  attack, 
the  Ixxly  lias  its  garrisons  of  protective  lymph  ntnles  around  the  road 
l.\  wiiic'h  the  invaders  are  most  likely  to  come— the  upper  air  passages. 
Partides  on  the  surface  are  constantly  being  deported  by  the  mucus 
and  >aliva,  in  which  they  lie,  being  carried  toward  the  entrance  by  the 
(ilia  of  the  ejMthelium  lining  tho  tract. 

4.  Protection  by  Leukocytes. — On  mucous  surfaces  there  are  fre- 
(|ii.iiti\  free  leukocytes  that  have  wandered  from  the  bloo<i  stream 
ill  t  ween  the  superficial  cells.  These  engulf  particles  of  dust,  bacteria, 
etc.,  and  wander  back  with  them  into  the  tissues.  Apart  from  the 
ilige-tant  or  solvent  effects  of  the  cytoplasm  of  the  leukocyte  up(m 
it>  (aj)ti\e,  the  foreign  body  is  thus  imprisoned,  and  for  the  time  being 
not  (•ai)able  of  doing  hurt  to  the  body.  No  commonwealth  fears  very 
LTcatly  criminals  or  other  enemies,  if  each  criminal  is  handcuffed  to 
.1  poIiV.tnan.  The  leukocytes  which  wander  back  to  the  tissues  are 
larric.l  by  the  lymph  stream  to  the  nearest  lymph  node  where  the 
intruder, "if  a  bacterium,  is  killed  by  the  leukocyte  or  if  the  leukocyte 
Ik  wcikeiied  by  its  struggle  with  the  bacterium  both  are  engorgeil 
!>>  line  of  the  large  endothelial  cells  the  macrophages— which  line  the 
1,\  iii|ili  sinuses.  Haderia  are,  thrrrforr,  cimstantb/  findimj  thel,  way 
nitn  the  tissues,  but  under  such  circumstances  do  not  cause  infection. 
hi  liHilfh  they  are  destroyed  soon  after  their  entry. 

Tins  process  is  going  on  coi\stantly  in  the  tissues  underlying  all  the 
iiKii-t  surfaces  of  the  body,  and  in  none  to  a  greater  extent  than  in  the 
intestines,     It  is  scarcely  credible  that  the  absorption  of  so  many 


88  THE  (WrSKS  OF  DISEASE 

leukocvtcs-  tl.c  s..li.l  internal  ornans     spleen.  k..lne>,  it(.     Iism  i    t- 
.V         .    ..ntain  l-aeteria.  hut  ap,.reeiahle  «n.wth  tr.,m    'j"^"   ^  ;;^-; 
e  unml.h  l.eeause  .n..st  ..f  the  haeteria  u.  a  given  or^an  at  the  m<  m  nt 

■mm  the  cireulating  1.1.....1,  an.l  after  an  hcur  pn.hah  >  none  at  .  . 
S  e  ot  elh  n  -t  the  hlu.-.l  vessels  ..f  al!  the  organs  has  l.een  aetue 
h  Urn  vh  K  t  e  haeteria.  the  ieukoeytes  have  hen.  e.ujulhng  U,e,a, 
a  u  the  Inuteri.i.lal  snhstan.e.  of  the  hlo.-l  ^-"'"^  .^'-"'-^^  ^,^^ 
h  rs  h.ter  however,  the  l.h.o.l  is  again  teennng  with  them.  Ihis 
m".  :rsorattem.ate.l,  half-kille.l.  or  nninjnre.l  haeteru.  tneked 
awVv  in  some  .-orner  with  insnfti.iently  powertul  <els  ..j.pose.l  to  htm. 
Jm^aite     heir,.pportn.,ity.  havewon  their  U.ealhattle,an<  mult.pl 

t:,    Mn    the  tilsues  now  exhau.te.i  of  thc-ir  P-^-;''-    ^--J 
one  uses  a  ho.nelv  example,  the  inroad  ot  the  haeter.a  is  like  a  pra  ne 
fire     tta.k  Hi  a...i  heaten  out  hy  an  arn.y  of  fire  fighters;  son.e  sp<.t  let 
!^;Xing  hi.les  its  tin.e.  an<l  hla.es  up    tlu^  fire  Meters  exhaus^^l 
hv  the  previous  struggle  <annot  .ope  w.th  >t,  a...l  .t  swee  s       er 
thh.g  hefore  it.     It  is  possihle  to  fi...    ...  m.eroseop.e  r^-'-f<  '  ^ 

liver  .lots.  si.,gl.-.  .l.mhle.  or  trel.le.  wlu.-h  are  the  re,na..,s  ..1  hacttr  a, 
a,..i  ..tte,.  wh.'.ie  ha.teria  the.nselves.  Granting  all  the  h.reg.nng  e^.- 
,ie.H-e.  nevertheless.  //,.■  hrnHlut  tix.m.  are  potrnhnlhl  f^'l^,  j 

Modes  of  Infection.  Sin.r  th.re  are  many  ways  In  ;^  1"\'\  '  •»^^; "^ 
e..t.T  the  tiss,...s.  it  is  evi.le..t  that  th.Te  are  ma..y  ways  hy  wlueh  mfec- 
tio..  ean  arise.  Infe.tion  i.,.plies  n.-t  the  .nere  pjTsenee  ..r^  the  s,.e  . sv- 
f„l  muttiplieation  of  haeteria  ...  the  t.ssi.es.  I  he  ta.t..rs  that  makt 
po»ihle  the  latter  are  these: 


EXOGEXCrs  JXTOXKATIOSS—l'ARASlTIC  CMSKS 


SO 


1.  Traumatic  Solution  of  Continuity  of  the  Surface  Layers.     Hen'  an 

ingress  is  i)r()\ ided  for  the  l)a(tt'ria.  and  tin-  damaged  tissne  is  a  fa\<ir- 
al)le  gronnd  for  tliem  in  wiiicli  to  mnltiply.  This  lowered  vitality  r)f 
tissne  is  most  important.  The  resnlt  is  familiar  to  everyone  who  has 
seen  an  infeeted  wonnd.  Let  ns  follow  the  im)eess  in  a  wound  of  the 
^kin;  lying  deej)  down  in  the  layers  of  the  skin,  and  in  hair  foilieles, 
is  the  Staphylocoeeus  epidermidis  alhus — perhaps  an  attenuate«l  form 
of  the  ordinary  staphylocoeeus.  hut  leading  a  harmless  saprophytic 
existence.  Let  a  tight  suture  in  a  wound  lessen  the  hhxMl  supi)ly  of 
tile  underlying  tissue,  this  organism,  so  weakly  pathogenic  that  it 
cannot  live  within  the  tissues,  has  power  to  grow,  to  increase  its  viru- 
lence and  to  break  down  the  tissues  already  weakenetl  by  the  trauma 
of  the  knife  cut.  This  is  the  genesis  of  "stitch-hole"  abscess.  Further, 
the  organism  which  infects  the  wound  need  not  be  a  local  inhabitant 
of  the  tissues;  we  have  pointed  out  that  there  are  bacteria  of  many 
Mirts  leading  a  brief  e.xistence  in  the  circulating  I)Io(h1;  one  of  these 
ill  the  few  moments  of  life  that  would,  unfler  normal  circumstances, 
remain  to  it,  may  be  carried  to  the  damaged  area  of  the  wound,  where 
it  finds  the  tissues  in  a  state,  not  only  not  inimical,  but  even  favorable 
til  its  growth.  Such  is  the  genesis  of  some  wound  infections.  Every- 
iiiie  who  has  followed  the  work  of  a  busy  surgeon  has  seen  "aseptic" 
uperatixe  cases  become  infected,  and  die;  heart  burnings  and  self- 
iicciisatioiis,  and  suspicion  of  the  assistant's  fingers,  and  of  the  instr a- 
iiieiits,  and  of  the  ligatures  have  followed,  all  of  which  tends  t(»  keep 
an  oi)eratiiig  statt"  eternally  vigilant.  This  is  a  good  result  following 
a  tragic  alfair;  we  would  not  lessen,  for  an  instant,  the  mental  effect 
of  >iich  cases,  but  we  cannot  refrain  from  indicating  the  methtKl  in 
which  such  an  accident  iiia;/  occur. 

'2.  Alteration  of  the  Surface  Discharges  and  Secretions. — When  in  " 
tV\er  the  salivary  secretion  is  lessened,  the  mouth  becomes  foul  and 
liiicteria  instead  of  being  swept  away  remain  /"/(  nilii  and  multipl.v; 
tlieir  toxins  cause  necnt.sis  of  the  underlying  surface  epithelium,  and 
mi:  nicer  results,  so  that  there  is  now  jm)vided  a  suitable  medium  for 
yritwtii  of  tlie  bacteria  in  the  damaged  ti.ssue  and  an  entrance  into  the 
l>ii(ly.  Similarly  in  the  bowel,  if  an  obstruction  occur,  the  bacteria 
in  tlie  contents  above  the  obstruction  multiply,  give  off  increased  toxic 
linHiiicts,  and  rapidly  increase  in  virulence,  an  observation  that  is 
niidiiy  verified  by  exi)eriment. 

'■'.  Growth  of  bacteria  and  infection  in  an  internal  organ  with  no  recog- 
nizable solution  of  continuity  of  the   surface — "Cryptogenic  infection." 

All  osteomyelitis  of  streptococcic  nature,  for  exami)le,  is  seen  to 
iri--f  without  any  surface  injury  or  recognizable  trauma,  or  a  joint 
111  rlieiiniatic  fe\er  is  aspirated  and  a  coccus  is  cultivated  therefrom. 
1  lli^  is  clearly  a  case  of  cryptogenic  infection.  Why,  then,  if  bacteria 
:irf  ill  tile  circulating  blood,  is  it  not  a  constant  occurrence?  There 
Jirc  (lonlitless  several  factors  which  nmst  be  concurrent,  but  one  of 
'liiiii  is  that  there  must  be  the  requisite  quantity  of  infection.     Ju.st 


go  THH  CAUSES  OF  DISEASE 

""  -;-V""- .  -'"  'r'T'i:;.' e":  1  S       rule."  can  har.Uy  set  up  an 
by  a  leukocyte,  umU>.       '^^    "^  ;V,    '^^l.e  leukoeyte,  are  al.le  t.,  over- 
i„,Vet.ou,    .e.ause  tlu  ^'^'^  ;•„.;„,■  .^^.^iate.l  eircumsta.urs  are 
eon.e  .t.    .^^^Xlt^  •  a^'o-lly  "-nn'-  c.f  haeteria  up..u  some 
neee>sarx  :    (1 )  t  a  1  ^^  "^  '^^^^         K      ^^^^^^    U-ukocytes  passu.K  .n.t  au. 
nu.cuussurfaee;  (2)  Y'"'  ^  •.      !'     u-cumu  ati.n.  of  so  many  bacteria  at 
-t""''T;i't  Ih^ii  r"it     ce  uZul^s  exhauste.1.  and  prohahly 
one  spot  t hat  t  u  ''^f    '\p^  ^^^  ^i,-,,  ,,,,.,  Move  the  hactena  were 
S.=    ^M^^i::^  is\h:;r^>:   >n.on.e  of. a  contest  between  the 
Etoria  an.1  the  tiss,.es>  whicl.  t»^--  ^  ^^^,,  ,,,3  difTereut 
How  Bacteria  Enter  the  Body.    fW  „,.y,r  „i,i„s.  others 

in  whi.li  to  siroNV      lhe>  can    »«  ^"         •      .  ^.„ts,  in  dust,  ui 

water,  nulk,  or  too.1  taken  h},  an"t"«'J  ,  '    •     ^^     bacteria  do 

mmmm 

;','r;,i;r"a..aM,„it.,t  .1,..,„:,K,.<  »t ,.  ,».i.it  ..t  l..wer«l  rc,„mnce 


EXOGENOUS  I SrOXlC ATI! >\R— PARASITIC  CAUSES 


91 


in  an  t-ntirely  diircrpiit  part  of  tlic  Ixwly.  Kereiit  oh^tTvatio.is  luive 
show  II  tliat  a  imriiial  lymph  ikmIc  is  not  a  lu-rfrct  tilt«'r  and  lliat  within 
a  ven  few  minutes  after  inoculating  bacteria  into  the  tissue  of  the  lejj 
tiiese  ha'  teria  may  be  found  in  the  circulating  IiIixkI,  past  the  inguinal 
iHMJes;  if,  however,  a  preliminary  inflammation  of  the  lymph  ikkIbs 
be  caused,  the  bacteria  are  wholly  arreste<l,  not  ap|)earing  in  the  bhuxl. 
'J'he  inflamed  luxle  is  then  a  perfect  filter  by  reason  of  the  complete 
filling  of  its  sinuses  by  cells. 

The  Virulence  of  Bacteria.-  The  viruleiu-e  of  a  bacteriun  is  measured 
by  the  amount  and  the  (juality  of  tin  toxic  substaiues  it  liberates 
either  in  its  growth  or  in  its  disintegration,  for  tliere  are  ba<teria  which 
keep  their  toxins  shut  up  in  their  bodies  (endotoxins),  to  be  set  free 
only  when  the  bcMly  breaks  up.  These  toxic  substances—  united  under 
the  term  "toxins"-are  the  protective  substances  of  the  bacterial 
IhmIv,  compjifable  to  the  protective  substances  «,f  tin  animal  body. 
From  what  has  been  said  previously,  it  will  be  inferretl  that  virulence 
depends  upon  three  variable  factors — the  quality  and  the  amount  of 
toxins  and  the  number  of  bacteria. 

The  quality  of  toxin  is  specific  in  a  tw'')-fold  sense:  different  species 
of  bacteria  jjroduce  tlifTerent  toxins,  and  toxins  are  active  upon  some 
species  of  animals  and  not  ui)on  others.  Regarding  the  first  of  these 
>tatements,  it  is  true  that  bacteria  of  allii-d  species  pro«luce  multiple 
toxins,  some  of  which  are  common  to  all  the  members  of  that  group 
of  allied  species;  yet  others  are  specific  for  each  member  of  the  group. 
With  reference  to  the  second  statement,  it  is  necessary  only  to  men- 
tion the  gonococcus  which  is  active  for  man  but  not  for  the  lower 
iiiiimals,  and  members  of  the  group  of  the  hemorrhagic  septicemias 
iif  various  mammals  and  birds  which  are  without  ett'ect  upon  man. 

Nor  are  these  the  only  variati.-.is.  It  the  same  organism  be  isolated 
from  two  individuals,  ttie  virulence  of  the  one  strain  is  never,  or  hardly 
I  ver,  exi)eriniv  ntally  identical  with  the  virulence  of  the  other.  Further, 
;ilt<r;(tions  of  \ irulence  can  readily  be  pr(Hluce<l  ex])erimentally  by 
"passage"  through  the  bodies  of  animals  susceptible  to  the  bacterium 
(iiiicerned.  If  inoculation  of  a  pathogenic  dose  be  performed,  and  if 
iis  soon  ii>  symptoms  of  disease  ]T(.sent  themselves,  the  body  fluids 
cnntaiiiing  the  bacteria  be  inoculated  into  a  second  animal,  and  so  on, 
tin-  \ irulence  can  be  heightene<l  in  a  very  short  time,  so  that  a  much 
>iiiailer  dose  will  cause  d'sease  in  a  much  shorter  time  than  was  at  first 
till  case.  It  has  been  occasionally  noted  that  this  jjrocedurc,  while 
increasi-ig  the  \Irulence  for  the  species  concerned,  lessens  the  virulence 
tor  certain  othci'  species. 

Ill  II  iniiiiiKr  contrary  to  the  above,  there  are  certain  methods  at 
oiir  (li>posa!  by  which  the  virulence  of  a  bacterium  can  be  lesseneil. 
rhii>,  by  iiolnnj^ed  growth  upon  media,  with  transference  at  long 
iiitiTvals,  the  \ irulence  of  all  i)athogenic  bacteria  is  lessened;  bacteria 
"stewing  in  their  own  juice"  rapidly  lose  virulence.  Certain  other 
iriicedures  eil'ect  the  same  end,  such  as  prolonged  growth  at  a  tempera- 


l»i 


TIIK  <-.\rSKS  (iF  l>ISK.\Sh: 


to  a.lva.ur ;  if  to.,  .litH.ult   >t  »";-"-;  '"'n  ,    "  ;,.llv  hijjh.r  i..  th.  s.h|. 
Other  Pathogenic  ▼•K«»»Werornu..    H"    -Mn  '^      f,,,       -,.  i,,,,,,,^. 
than  the  hactoria  ..r  s,lu/....ny.Hf>.  l^'^_l^^;j^  ,„„;,,  Umus  ..f 
t„„.v  an-  s,n..lrv  Kvp!u..".y.vtos    a  u      .la  t     ^      t^       .U,ll„p„u.n,  of 

l.„m.hran.-hin>r  fih.nu-uts  ..r  l,yi>ha',  tho  la  U  '^'^\       ,,^   ,,,„,,,;       „, 

wfll  as  l.y  sp..rul.it.on.     1  h  •>.   t.  rn  >  an  j^      ;      ,,.,,;,,,,  ^.„,  first 

orpinisin  of  J.laston.y.rt.c  '»«'"""t'^'r;, !  ;^  '  ^  ^  ^  'Uhihits  onlv  tho 
,,Lv  ,  i..  N.,rth  A"u;"- -^-  -  ^  ^  ^ri;;  im^lia  outside  the 
n.un.le.!.  l.u.l.l.nK  form,  al  h..i  U.  ''\\l^  ,■  ,^.twe.-n  these  and 
,„„ly   it  develops  .hst.nct    hvplue     ^f'^^^^^^  ,„,.,h  nu.re 

the  hacteria  pn.per  are  tlu-  ^«7''"»'''  /" '' V\^.  U^,'  he  rav  funpu>  or 
,„i,.ute  than  the  -«'"X  '  :|'' tvl  ;  'H,  t^I"  f.-s  whieh.'while 
aetiiu.inyees  may  >e  taken  ■'yM";  '  .  .  .„j  ,,,,,1^^.  those  haeiUi. 
H,vi„,  the  sanu-  .Ijameter  as    he  -«^';'^^^^   ^  to  form 

eshihit  true  hranehm,  and  V.!  "'S.;'  "!v"v  closely  relate.!  t<. 
a  .ny.elium  ..r  telte.l  mass.  l'>7''  ""'; V/' ". -.h  also  under  favorable 
th..  tuhenle  l.ac-iHi  «|"l  '"••^l"'^  '""-t*"""  .  ^  ^'  ^/r,;  .  tfere,>tiate.l 
,„„.,iti.,n^  n,ay  exhil.it  true  hranc-hing.  ^,  »^;  "^/^^^i  .  ;".,f  .lisease. 
:r  ^^'^'^^V"":; ';  SJr:   •  /r.te  Jirl's^n^rtina.  ..evelo;.- 

linl,.  or  ,u, ,,...»  t„  f.,n„  t„x,ns.    Am„„B  '"'"^J",    ";„;„,„!, 

the  t.>s  e.     It  ^     ',/',,„,  i„tra.tal.lefonn..f  inflammat.o..,thou^'h 

;;„  ,;,l,';,';iJ  ™,,.r,.  r.,,.n,l.li,.B  i..  many  „•»,«*  tl,.«.  ...,hu,..l  l.> 

""Mibii'Tit:  ,„  ,„„,„  „,.  „„,v  ,.>„.  ,ha,  'i-<<; » ;;-«^' 

iierkefel.!   Hlter.     Ol   thes.  .lis.uses  we   may   mention   >ell..w    k^.r, 


PROTOZOAS  PARASITES  AS  CACSES  OF  DISEASE 


m 


ploiiropiH'iimiMiia  of  cattU',  vaccinia,  scarlet  fever,  ami  pruhablv  measles. 
It  is  |K>ssihl<'  that  here  we  «leal  with  ultrarnicrosciipic  orjtanisins  of 
more  than  one  Mnier.  Tims,  the  carriage  of  yellow  fever  by  mosqitit(H>s 
suiTKcsts  that  this  disease  is  caused  by  an  orftaiiism  of  protozoan  nature, 
v  'ile,  on  the  other  liand,  rewnt  researches  u|mhi  the  cultivation  of  the 
oPKiinism  of  l)ovine  pleuropneumonia  indicate  that  this  is  allie<l  to  the 
schizoin>  fetes. 


PROTOZOAN  PARASITES  AS  CAUSES  OF  DISEASE 


^4^ 


There  are  certain  parasites  Itelonpii);  to  the  division  of  the  protozoa 
wliich  can  cause  disease  in  man;  these  belong  to  different  orders  of 
protozoa;  thus,  for  example,  the  entamceba  is  one  of  the  sarccKliniie, 
the  trypanosoine  of  the  flagellata,  the  malaria  orpmism  belon>;s  to 
the  sporozoa,  antl  Balanti<lium  coli  to  the  ciliate  infusoria.  One  is 
tenipte<l  to  try  to  find  analogies  between  the  protozoan  parasites 
iind  the  bacteria,  but  the  development  of  to.xiiis  by  the  protozoa  is  so 
slight  and  the  toxins  are  of  so  low  an  order  that  it  has  not  yet  been 
possible  to  develoj)  antitoxins  or  passive  immunity  by  experimental 
rncnns.  Here  certain  possible  exceptions  must  be  noted.  There  is 
now  no  doubt  that  the  Tre/Hmema  pnllidinii  {Spinx-hrta  iiallida)  is 
the  causative  agent  in  syphilis,  a  disease  exhibiting  a  well-marked 
immunity.  The  balance  of  evidence  at  the  present  moment  seems  to 
be  in  favor  of  regarding  this  as  an  animal  form,  although  there  are 
tliose  who  hold  that  it  is  more  nearly  allied  to  the  bacteria.  So  also 
protozoa  have  been  described  as  the  causative  agents  in  smallpox 
and  vaccinia,  two  disorders  presenting  remarkably  well-<lefined  immu- 
nity. There  is,  however,  increasing  consensus  of  opinion  that  these 
disturbances,  along  with  scarlet  fever,  are  induced  by  members  of  the 
uroup  of  ultra-microscopic  microbes. 

We  have  not  yet  enough  knowledge  of  protozoan  parasites  to  allow 
us  to  make  general  statements  about  them  as  a  class,  and  we  must 
lie  ciintent  to  set  forth  individual  points  about  the  most  important 
I 'f  these. 

Order  SarcodinisD. — Entamoeba. — The  Entamceha  hintohjik-a^  is  a 
iniitiie  mass  of  protoplasm  with  a  nucleus  and  a  contractile  vacuole, 
whicli  in  appearance  is  identical  with  the  am(pba  that  inhabits  ponds 
"f  stagnant  water.  They  are  not,  however,  the  same  species.  The 
'iitiiinieba  gains  entrance  to  the  colon  where  it  may  set  up  dysentery; 
it  attacks  the  mucosa  and  submucosa,  ingests  cell  debris  and  red 
lildod  cells,  and  may  exist  in  great  numbers.  When  it  infests  the  bowel, 
it-  action  is  aided  by  pathogenic  bacteria,  which  constitute  a  secondary 
intVction.     The  entanKcba'  are  carried  to  the  li\er,  where  they  often 

'  HcciMit  workers,  fallowinR  .Schaudinn,  make  a  distinction  between  the  cHlaimrba 
'•"li.  a  no.--;!!:!!  h.uniles.s  inhabitant  of  the  lower  bowel,  and  the  fnlamaehn  histolylica, 
'lie  causative  agent  in  tropical  dysentery. 


MMMki 


1 


MICROCOPY    RESOLUTION   TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No.  2| 


1.0 


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^  -APPLIED  IfVMGE  J 

^S-_  '653    Lost    M-j.r    -..treft 

~-S  t.\j':^esler.    New    York         '*609        uSA 

'^—  i  716)   482  -  0300  -  Pf'ore 

^S  '"^)    ^98  -  =1989   -  fan 


IfW 


94  THE  CAUSES  OF  DISEASE 

set  up  abscesses.  In  the  colon  the  entamoeb*  are  found  in  a  round^ 
enexSed  state  with  the  development  of  spores  wh.eh  m  turn  form 
new  entamci  S.  It  is  not  known  if  these  develop  entirely  extraceUnlar 
or  f  heT^iter  into  cells  for  their  development,  nor  u  it  known  that 
there  iT  a  toxin  prcKluced  by  the  organism;  the  remote  tox.c  effects 
seen  in  amoebic  cb^entery  n.ay  be  due  to  the  secondary  mfection.  or 
to  the  effects  of  cell  disintegration. 

Fio.  28 


Schematic  l.fc  cycle  of  tl.c  Eutmnaba  hMytica:  1,  the  adult  amoeba  wth  nucleus  W  and 
c<mm.cUlc  Hcole  (rt;  2,  the  .nme.  „>ul.ipl:in«  by  amitotic  division;  3,  appearance  of  ohrom.d..l 
11X1  in  cvtoplasm  which  enlarge  and  bocon.e  the  spores  in  4:  these  spore,  become  d.seharged 
or Tbe'tld  (5)  and  develop  («,  7.  8)  into  the  adult  amoeba,  or  (U)  under  other  condtt.ons  the  amcBba 
passes  into  an  encysted  stage.     (After  K.  L.  Walker.) 

Order  Flagellata.-^Of  these,  the  trypanosome  is  the  most  important 
tvpe  This  is  an  elongated,  spindle-shaped  parasite,  with  an  undu- 
lating membrane  along  one  side,  which  is  connected  at  the  head  end 
with  a  refractiie  grannie,  the  microniicleus,  and  beyond  the  tail  end  is 
clongate.1  into  a  flagellum.  There  is  a  nucleus,  and  sometimes  a  con- 
tractile vacuole;  multiplication  occurs  by  longitudinal  division,  ihe 
dimensions  of  this  protozoa.,  may  reach  30  or  even  r,0|x,  with  a  breadth 
of  2  (.r  3 M-  i»"'l  '"  »"rp^''l^  ''rii""  ''''">•'  't  "!">'  ^'^  ^<'^"  l«^n»"K  ^"  and  fro 
in  the  Held  among  the  l)li)o<i  corpuscles  like  a  wounded  snake  among  dry 

Its  importance  is  great.     Civilization   might  overlook  the  :?(),0()0 
blacks  who  are  estimated  as  the  annual  victims  of  sleeping  sickness  in 


PROTOZOAN  PARASITES  AS  CAUSES  OF  DISEASE 


95 


West  ami  Central  Africa  from  T.  gamlncnse,  l)ut  deplores  the  millions 
of  dollars  ann.ially  lost  from  T.  etansi,  and  T.  brucei  infecting  horses 
and  cattle.  The  forms  of  disease  so  caused  are  surra  in  Assam,  India, 
and  the  Philippines;  n'gana  or  tse-Ue  fly  disease  in  Southeast  Africa; 
dourine  or  mal  de  coit  in  Algeria  and  Southern  Euroj)e,  and  in  Nf)rth 
America  by  importation,  and  mal  de  Caderas  in  South  America.  The 
so-called  Donovan-Leishman  bodies  found  in  the  enlargerl  spleen  in 
kala-azar,  or  dumdum  fever  of  man,  have  been  proved  to  be  a  stage 
of  a  trypanosome,  as  is  the  allied  body  found  in  the  sores  known 
variously  as  Delhi  biil,  Alei)i)o  button,  etc. 

Fio.  29 


^'^^^^^ 


TrypanDSonies  (T.  Kamhionsc)  from  the  blood  in  sleeping  sickneM.      X  2000. 

So  far  as  is  yet  known  simple  longitudinal  fission  is  the  only  mode 
III  multiplication;  only  this  mode  has  been  seen  in  trypanosomes  gn»wn 
ill  media,  but  it  is  quite  possible,  even  probable,  that  other  stages  in 
ilii'  life  cycle  do  exist.  Without  dealing  a*  length  with  the  evidence 
'liiit  already  exists  in  favor  of  this  view,  it  may  be  said  that  in  Halter- 
idium,  a  |)arasite  found  in  the  blood  of  the  owl,  a  frc*-  trypanosome 
Inrm  has  been  foinid  in  the  fluid  part  of  the  blood,  and  an  amoeboid, 
niiii-Hiigellate  f(.>rin  in  the  cori)uscles.  There  is  evidence  that  the 
trypanosomes  of  disease  have  a  minute  latent  intracellular  stage. 

Tliesc  forms  of  protozoa  are  conveyed  to  man  and  warm-bloo<iefl 
iiiiimals  by  the  bites  of  insects.  Tse-tse  fly  disease,  which  a  quarter 
I  if  a  century  ago  invested  this  insect  with  all  the  fatality  and  mystery 


m^..£mi^mfmm 


9G 


Tii::  CACSES  of  disease 


ness  hy  Glc  sina  palpalis-  h..th  flies  ,.t  tl.e  "horse  fly  type.  Ihese 
take  the  trvpanos.>mes  int..  the  stomach,  syhence  they  reach  the  tissues 
and  ire  .U;char>je<i  with  the  flui.l  h.hr.catu.K  the  mouth  parts  in  ..  the 
flesh  bitten  h^■  the  flv.  N<»  exi)erimental  means  have  yet  demonstrated 
the  presence  of  toxi/.s,  an<l  the  symptoms  are  ana-mia.  moderate  tever, 
the  existence  of  crdemas,  depression  of  cerebral  a.tivity  and,  hnally, 

"""Ser  flaL'elhita— the  trichomonas  and  mesastoma-are  found  in 
the  intestine,  hut  the  cases  in  which  they  have  been  proved  to  be 
associated  witli  disease  are  distinctly  rare. 


Fia.  30 


L- 


Gl.wsina  iwliwlis  (  X  33),  thi>  carrier  of  ihe  trypanuaonic  of  sleeping  sickness. 


Order  Sporozoa.  -These  (.r^anisms  are  characteristica'ly  intracellular. 
The  parasit*-  enters  an  individual  cell,  arrests  its  function  and  causes  its 
death  the  cvcle  of  life  of  the  parasite  bein^'  such  that  the  spore  formation 
roushiv  corresi)onds  with  the  time  o!  death  and  disintejtration  of  the  host 
cell.  The  spores  set  free  >;rovv  into  small  amcrboid  forms,  which  enter 
other  cells  and  repeat  this  asexual  process.  Hut  a  sexual  cycle  also  exists 
especially  in  the  process  of  transmission  from  host  to  host,  and  this  sexual 
cvcle  is  carrie<l  out  in  the  body  of  the  carrier,  which  is  of  another  species. 
In  malaria,  for  example,  the  asexual  cycle  is  carried  out  anain  aiK 
again  in  the  huinaii  body;  the  mosfiuito  (Anopheles)  sucks  infected 
blood,  and  the  sexual  cycle  occurs  in  the  body  of  the  mosquito,  the 


PR(  rOZOAN  PARASITES  AS  CAUSES  OF  DISEASE 


97 


sfiorozoites,  the  products  of  the  sexual  cycle,  being  introduced  into 
iiuotluT  human  host  with  the  proboscis  of  the  mosquito,  there  to  enter 
once  more  into  a  series  of  asexual  cycles.  Transmission  by  insects, 
though  the  most  frequent,  is  not  the  only  mtnle  of  transmission  of 
sporozoa,  for  cocridia  enter  the  digestive  tract,  and  others  supposedly 
ny  the  respiratory  tract. 

Hematosporidia. — The  j)arasite  of  malaria  is  the  type  of  this  sub- 
order, and  oiT  knowledge  of  it  has  been  greatly  assisted  by  the  study 
of  allied  forms  in  birds  and  other  animals.  The  most  important  facts 
relating  to  malaria  are  these: 

1.  'J'he  disease  is  transmitted  by  the  Anopheles  mosquito,  and  is 
endemic  or  epidemic  only  where  these  are. 

2.  The  Anopheles  lays  its  eggs  in  still  water,  and  the  larvae  are 
ac|natic;  the  mosquito  does  not  travel  far,  save  with  high  winds,  and 
malaria  is  thus  largely  confined  to  the  neighborhood  of  swampy  or 
badly  drained  regions. 

3.  The  Anopheies  does  not  bite  in  broad  daylight.  Infection,  there- 
fore, occurs  in  the  evening  or  at  night. 

4.  The  asexual  cycle  of  development  requires  different  periods  of 
time  for  the  different  species  of  hematozoan — forty-eight  hours  for  the 
organism  of  tertian  fever;  seventy-two  for  that  of  quartan;  forty-eight 
(with  irregular  variations)  for  that  of  the  estivo-autumnal  type.  The 
|)ti iodic  chills  and  fever  coincide  with  the  maturation  and  sporulation 
of  the  parasite,  the  damage  being  probably  wrought  by  the  liberation 
of  cell  debris  and  pigment  rather  than  by  any  specific  toxin  of  the 
])iirasite  itself. 

5.  The  cell  debris  and  pigment  so  liberated  are  carried  to  the  spleen 
and  there  set  up  the  changes  that  lead  to  the  enlargement  of  that  organ. 

(i.  Prolonged  asexual  reproduction  seems  to  weaken  the  parasite, 
<o  that  if  re-infection  doe>  not  occur  the  disease  gradually  passes 
•  ill';  young  children  seem  relatively  resistant  to  the  disease.  Yet  it 
.ippears  that  the  parasite  may  lie  latent  in  the  tissues  for  long  perio<ls 
and  then  become  active  again;  clinical  experience  seems  to  show  this 
f^ixcially  in  the  case  of  the  estivo-autumnal  type. 

Otiier  sporozoa  are  unimportant,  so  far  as  the  human  race  is  con- 
'iriicd.  But  it  must  be  pointed  out  that  forms  very  like  stages  in 
tlie  sporozoan  life-cycles  have  been  found  in  the  cells  in  vaccinia,  small- 
piix,  and  scarlet  fever.  The  relation  of  these  to  the  diseases  in  which 
tlii'X  are  found  is  not  yet  clear.  Pathologists,  in  general,  are  doubtful 
whether  tliey  are  of  protozoan  nature.  B(Mlies  of  a  supposedly  sporo- 
/iiiiii  nature  have  been  from  time  to  time  demonstrated  in  the  cells 
'I  malignant  growths,  especially  cancer,  but  the  idea  most  prevalent 
at  i)resei)t  is  that  these  are  not  sporozoa,  but  that  they  arise  by 
■li  ticncration  of  cytoplasii    or  of  nuclei. 

Order  Ciliate  Infusoria.  The  Balantidium  cell  is  found  in  the 
ilinicntary  canal,  associated  with  inflammation  of  the  colon,  but  its 
'  aiisative  relation  is  not,  as  yet,  definitely  proved. 


} 


THE  CA  USES  OF  DISEASE 


no  Ttlt'   i,/"uoi^u  v^- 

spirochetes.^  (.eat  .ntcest  ^1^:^^^:!^:^^^ 
organisms  causin,  K»-pean  and  Af nc^^n^^^^^  ^^^^_  ^^^    ^^p^. 


.,1^1 ■     ,.   ,'    ,    5^ii„:-\   frambOBsia  (or  yaws),  ami  ay !»"»»"• 

These  ..rganisn.s  are  n"'-">^'  f '  f^  ^tsence  of  terminal   flagtjla, 
spirilla  ^^ro,>er^r7l      ZmI^^^^^^     both  extremities     They 


Fia.  31 


:4 


ti„ :,s  that  this  IS  l..nptu.lu.al.  »^ '^  J'"^  that  transverse  division 

staten.ent,hyotherequaUy  c.nnp  t  n^^^^^^^^  ,„  ,,,,t  of  the 

obtains.    Their  behavior  to^^a^l  ^^^^^^^  "^^^  ^     ^j^^  pin.plasma. 

trypanosoim.  to  ^^^^ -^;;il^::^^;,X to  trypanroth.and  the 
;;;;r^Sr;:rd^;^ni:,^  to  wel^h  downthe  scale  m  favor 
of  their  protozoan  relationships. 

METAZOAW  PARASITES    AS  CAUSES   OF  DISEASE 

1, ..  v-lufh  are  of  inirortance  as 
The  parasites  ot  .ho  ■"«»»■:;  !',*;».<*«  ..r  flat-worms, 

sr'"^-ss;;Vr';;;l;;:r:..n.:;:  ti'e '-«« -<• "« -"«""'* 

"V*;t,..a».a„  ,>ara,it,.s  in  «--«!   take  ..eir  feed  »  a J^par^l 
state  horn  their  liost,  so  that  iheit  d.6l^.tl^e  =.M< 


iyjwr*nwrt 


s, 

?s 

A. 

m 
a, 

ey 
ne 


erva- 
e  the 

>f  the 
asma, 
id  the 
favor 


lice  as 
ivorms, 


repared 
only  of 


PLATE   II 


1       llyiliril'   fiTITi 

„'.    I'imiii'iitr"!   niii;  fMrn 
;!  tii  li.    I'lLMiii'Tiic'l  f"rrii 


Fic).  1. -Tertian  Malarial  Plasmodium. 

i,,^  forms.  ''    Noll  fl:ii:i'll:iie  f'Tiii.  (Macro- 


, .  >t'jriiieiitinir 

s.    1  liiL'ellMli-    fiinn.         Mii'P.iru- 

IlllMnt'Vte.l 


l.MMH'tC.1 

111,    SciiiiuMiliim    fi>rMi    .'iftpr    cle- 
-inu'l'oii  <if  rr'l  fi.r|>ii-fU\ 


1.    l|y;ilinc  f.irni. 

J  I,.  ."..    I'iniiic'Hti'.l  fi.riii- 

i;  ;ili.l  7.    .-(•u'lm-nlih!.'  ("nn- 


Fig.  2.~Quaraan  Malar'ial  Plasmodium. 

-,    Sem,»..,linL'  form     after  ihe         (1.    IImki-:!;!!.-   l..n„.      (Mirmm- 
,l,.,lriicli(.n  of  re.l  .-..rims-  ■nci..i-Mr.i 

lie.  III.    Ni.n-ll:iKi'llcite  form.   iMucro- 

guiiiete.l 


Fig.  S.-Teriiaii  ^suvo-autumnal  Malarial   Plasmodium. 

s     VoiiMi:  ,i,tnw..n.iiMMil:.rcr<--  111,    lla^.-llalo    f..rrii.      AUrmua- 

,.,.„,  ,„..l..c.vUM 

(I    Scu-in.-ntinL'f..rtM-.  u  m  11,   (>..-.■.■,.,,.    '..rnis. 
,  :,tv\  Ir    I'lL'liuMilc'.l  l..rni- 


!    ;1TI.1    1      ll.^Miilll'  Tim:  I'TIll, 

J,  ;):m.      ,  I'i-mi-mi-il  rimr  U'f 


Fi  1.  4. -Quotidian  /Csii  vo-autumnal  Malarial  Plasmodium. 


S,.ir,,„.niiTiL' f..rm.      SeL'mpn-       In.    1 1 ..    l:i    aii.l    l.V    (■resr....iic 

laii.ir iii'lcic  \ntliiiiin-  lorm-. 

i.fli..i  ri'd  1)1 Icori.u-i-lc        |  _.    iK,,i,lf,,rm 


1  I,,  1.    lUalimMim-'lorm-,    >"mc 

,.,.1U    sti'iw    ilili>i-li,.ii    uilh 

nil  ri'  lli;iTi  "iii"  uriiaiii-rii. 
-  1,1  -     I'ii-im-nn-l    f'lnii-.      Ill   "         "     I  l:iL'|.nai('    f'irrn.       iMicroua         n     Non-llaL'cllaic    f-irms      (Ma 


Nou.       Mark  til,.  lari.-.-r  -\m-  an.l  t'rvai.T  am.mTil  ..f  i.iirmi'i.t  in  tl-  tertian  xi-ln.i. 


auiiiiiiiKil  i)la:*i>itMliuni, 


Fro.  1 


PLATE  II 


li.i.  •_> 


4 


7 


1(1 


V    *. 

10 


/) 


< 


Vu:.  3 


11 


13 


f^: 


Vu:.    J 


i^. 


3 


5  '  ■  *  .       4 


<?y 


,  15 

7 


10 


10 


14 


13 


II 


■:§, 


12 
14 


■■  I'-  Crai^,  Del 


Irf 


METAZOAN  PARASITES  AS  CAUSES  OF  DISEASE 


90 


tlu'  simple-t  sort;  sonu",  us  the  tapt'-\i<»rni,  dispense  with  un  alimentary 
tiaot  an«l  iVe<l  by  absorption;  their  organs  of  locomotion  nee<l  not  be 
( ( .mplicatt'd ;  their  organs  of  offence  are  only  such  as  enable  them  to 
penetrate  the  body  of  the  host  to  their  f«MHl;  their  organs  of  defence  are 
such  as  to  protect  them  from  digestion  by  the  bmly  juices  of  the  host. 
A  certain  j)ower  to  live  apart  from  the  host  assures  the  continuance 
of  the  species,  but  this  last  is  safeguarded  best  by  their  enormous 
repnxluctive  capacity.  Some  of  them  are  merely  animated  masses  of 
repr'xluotive  glands,  the  quantity  of  ova  being  great,  because  most 
of  it  is  destined  to  fall  oii  barren  ground.  The  sinplicity  of  structure 
tends  to  greatly  lessen  the  atlaptability  of  the  organism,  so  that  we 
find  that  in  the  process  of  time  a  species  Wcomes  able  to  grow  actively 
only  in  a  particular  species  oi  host,  or,  if  there  is  alternation  of  hosts, 
in  a  particulif  series  of  hosts.  It  follows,  thus,  that  each  particular 
species  of  host  has  a  particular  set  i>f  parasites. 

The  capability  of  causing  disturl)ance  in  such  forms  is  not  great,  a 
state  of  affairs  which  is  to  be  expected  with  parasites  of  comparatively 
slow  development.  Such  disturbance,  too,  is  brought  about  in  several 
(iifVireiit  ways,  as: 

1.  Displacement  or  Pressure  Due  to  the  Presence  of  the  Parasite. — 
Although  this  is  in  general  negligible,  a  Filaria  nocturna  may  block 
a  lymph  vessel  and  cause  elephantiasis  of  a  member.  A  cysticereus 
ill  the  brain  may  cause  death,  or  the  cyst  of  Tania  echinococcua  in 
the  liver  may  be  very  large,  and  may  menj.ce  life. 

2.  Injury  Caused  by  Migrat'in. — The  filaria  migrates  through  the 
tissues  but  cause'-  little  or  no  damage  in  doing  so;  however,  on  the 
contrary,  there  may  be  much  pain  and  inflammation  of  the  muscles 
(  aiiscd  by  the  passage  of  larval  Trichince. 

:>.  Destruction  of  Tissue. — This  is  of  very  slight  importance,  and 
I  inly  to  l)e  considered  in  th«  case  of  a  parasite  like  Ankyhatomum 
iilitiiing  up  a  large  capillary,  causing  hemorrhage,  or  where  a  parasite 
like  Trichocephabis  boring  through  the  bowel  wall  leaves  a  hole  through 
u  liich  infection  may  pass. 

4.  Loss  of  Food  Material  Used  Up  by  the  Parasite. — Contrary  to  a 
common  belief,  this  loss  is  so  slight  as  to  be  negligible. 

.').  Disturbance  Caused  by  the  Excretions  of  the  Parasite. — It  has  been 

su])posed  that  the  metazoan  parasites  excrete  toxins  as  do  bacteria; 

-oine  of  them  certainly  i)roduce  substances  which  protect  them  against 

the  digestive  juices  of  their  hosts,  and  in  many  cases  the  bodies  and 

l>i)(ly  juices  of  the  parasites  themselves    re  toxic,  but  this  is  to  b» 

expected,  and  does  not  give  any  additional  proof  upon  the  questic. 

it  issue.     More  important  is  the  %ct  that  all  verminous  parasites 

ft  up  eoslnophilia,  an  increase  in  the  number  of  eosinophiie  leuko- 

>tes  in  the  circulating  blood.    This  undoubted  fact  is  evidently  due 

■ '  an  excitation  of  the  bone-marrow  tissue  by  some  irritant  produced 

the  parasites,  and  it  may  be  surmised  that  the  anemia  and  the 

idition  of  ill-being  are  due  to  the  same  or  parallel  intoxicants. 


Fiu.  VZ 


I,),,  Tin:  cAisKs  OF  i)isH.\.'<h: 

.,    r    /ou.  Irritation  or  Discomfort  Brought  About  by  tho  Preteuco  o! 

^  rirn..:.!.  ..ninM.ort.n.t  Hr..;  yet  the  ..™.  -^  ..^wo„^ 
I     ,lw.r  ini.rr.itiiiL'  iiit.'stiiui   purasitrs  may  cauM-  itching,  Kniminj,  »i 

:;;'  ;;:!;i:;  ::s:T\rX^^^y^  Li  ....  .onvnisions  m  t...  v.ry .,«,.,. 

THE  ENDOGENOUS  INTOXICATIONS 

Internal  Secretions.  Tlu  n-  arr  .rrtaii.  jilaiuls.  siicl.  as  tin-  livt-r,  v<hh 
..xf^jTs..^-t  on  vvl.icl-  r..rm  an.l  .liM-har.M-  into  the  hl.MH  a  further 
external  m< n tin...  se<reti..n.  having'  "o  or  httle  (-..nnee- 

ti.  11  with  the  first.    Tliere  are  glands 
hke  tlie  thyroid   wliirh.   havmn   no 
..hvioiis  secretion,  and  no  duet,  have 
heen  found,  nevertheless,  to  «i>seharne 
internally  into  the  Ixwly  juiees  secre- 
tions of  sreat  importance  to  the  b(M<y. 
There  are  even  structures  that  are 
not  recognized  as  glands  at  all,  such 
as  certain  sympathetic  nannlia,  which 
i.ppear  to  form  an  internal  secretion. 
And  the  end  is  not  yet,  for  we  know 
that  certain  portions  of  the  mucosa 
of  the  alimentary  tract  have  secre- 
tions,   called    hormones,    which    are 
necessarv  for  the  full  activity  of  other 
digestive  glands,  even  those  -ituateil 
at  a  distance.     As  distinct  from  en- 
zymes, these  hormones  can  he  isolated 
iii  a  state  of  relative  purity  and  are 
unaltered  by  heat.    In  this  class  we 
include  such  bodies  as  adrenm  and 
iodothvrin.    Much  of  the  information 
we  possess  abcut  the  internal  secre- 
tions i^  yet  fragmentary  and  we  are 
not  able  to  lay  down  general  rule^. 
hut  must  he  content  to  indicate  .  )me 
of  the  most  important  facts  hearing  upon  the  defect  <.r  excess  of  the 
same  as  factors  in  the  production  of  morbid  states.  ,u,.rnu\ 

Ssturbances   Related  to   the   Thyroid   Secret^on.^Dehcient   th  n.u 
semtion  may  show  itself  in  the  child  as  cretinism,  or  m  t  u  _adult  a> 
myxoedema,  the  latter  arising  from  mechanical  removal  of  tW  J«  ^ 
Srchexia  thyreopriva)  as  well  as  from  more  obscure  ;-"--"-«;;: 
its  atrophy,  or  intertering  with  its  proper  action.        ^et  i.sm  i.  con 
L'cnital-  the  cretin  is  ,,hysically  and  mentally  m  a  stale  uf  rr.anlation 
Se  achilt  in  years  remains  a  child  in  intellect,  or  even  an  imbecile. 


Cretin,  main,  ngwl  l»eniv-<.ni-  yciirs. 
tBournivillc  and  Union.) 


THE  KSlH)(tES(HS  IS'TOXKWTIOSS 


'01 


ilfiititioii  is  lute,  hikI  the  scxiihI  orf;Hiis  hikI  fiiiu-tioiis  lieliiycHl  ami 
iinpcrfVct;  tin-  stutnrt"  \<  smnll,  tin-  liirihs  sliurt  him!  thi«k,  tlu-  ft-atiires 
nmrsc  iiixl  fx|)r«'s.si(inl«-s.s. 

,Myx(r<lcMm  <U'v«'lo|»iiin  in  aiiiilt  lift'  has  many  sitniiar  ffatures;  tlwr*' 
is  a  iiiiicoiil  (i-dcnia  (lit'Mcc  tlic  iiaiiic)  of  tli«-  siiltciitaiu-oiiH  dikI  otli«>r 
tissius,  gradually  rt)lil>iii>;  tlu-  fmv  of  its  oxpn'ssinii;  the  foaturt's 
lucoriu'  lu'a\\ ,  and  tlu'  sulxiitaiu-ons  tissiu'  siitft-rs  a  cunnt'ctivo-tissiu' 
HVtTuruwtli.  The  skin  ht'conu-s  dry,  tin-  hair  <'oars«',  thick,  and  tcndinf; 
to  fall  out;  the  mentality  becomes  slow  and  the  memory  defective. 
The  same  train  of  symptoms  may  Ik*  set  up  by  complete  removal  of 
the  thyroid  Kl»"d.  Thyroi<l  extract  can  cure  myx<c<lema,  and  cretinism 
ill  tlio  child,  hut  requires  to  he  niven  from  time  to  time  to  prevent 
ncnrrcnce.  It  is  to  be  noted  that  in  s«)nie  cases  of  myx(edenu»  and 
cretinism,  the  thyroid,  far  from  Ihmiik  absent,  is  enlarj^ed;  despite  its 
size,  we  do  not  supjMise  that  it  functionates  properly.  It  may  i)e  that 
the  vesitles  are  expanded  by  secretion  as  the  air  sacs  by  air  in  emphy- 
sema, so  that  the  walls  and  the  blo«Mlvessels  are  compressed,  with 
n   iiltinf;  arrested  absorption. 

The  opposite  condition,  clinically,  to  myxo  dema  is  exophthalmic 
goitre,  known  also  as  Graves'  disease  and  Basedow's  disease;  here 
(iiic  finds  too  much  thyroid,  or  too  active  thyroid  tissue,  with  result- 
iii),'  ntTvousness,  tachycardia,  tremors— features  opposed  in  character 
til  those  of  myxa'dema.  The  striking  features  of  the  disease  are 
the  exophthalmos  (probably  due  to  irri+ati(m  of  the  sympathetics), 
Mild  the  goitre.  Tremors,  great  nervousness,  and  tachycardia  may  l)e 
present,  indicating  a  nervous  energj'  far  ditferent  from  tiie  placidity 
nf  the  inyxa'dematous  patient.  There  is  heightened  metabolism  and 
iiMTciised  discharge  of  the  prcMlucts  of  tissue  disintegration.  Thyroid- 
1 1 1  iny  often  pnMluces  go<Hl  results. 

Disturbances  Related  to  the  Secretion  of  thj  Parathyroids. — Situated 
ill  or  near  or  under  the  thyroids,  varying  in  number,  are  small  pca- 
!i!vc  glands  calletl  the  parathyroids,  which  histologically  look  not 
nnlikc  the  immature  thyroid.  Their  removal  in  animals  is  followed 
I'  tetany,  cophthalmos,  rapid  respiration,  etc.,  which  symptoms  are 
iiniliorated  or  removed  by  the  use  of  calcium  salts.  In  many  opera- 
'  "IIS  for  thyroidectomy  in  the  human  In'ing  th?y  are  doubtless  removed, 
'itliont  any  apparent  change  being  wrought,  although  the  frequent 
;  rc-cncc  of  accessory  thyroid  and  parathyroid  no<lules  in  the  neck 
'  -ion  makes  it  difficult  to  be  si;re  in  any  individual  case  whether 
i  I  ri'  has  been  complete  ablation. 

Disturbances  Related  to  the  Secretion  of  the  Pituitary  Body. — The 

'iini  of  the  pituitary  btnly  is  related  in  some  obscure  way  to  that 
tlie  thyroid.  Acromegaly  is  a  remarkable  disease  which  arises  in 
iiuction  with  disturbed  functicm  of  the  anterior  glandular  part  of 

'  pituitary  body,  supposedly  in  the  direction  of  overactivity.  The 
lii^f  is  chanu'tprized  by  gre.Tt  (Mil.-irgpmpi't  of  the  mpml>ers;  the 

;\illary  bones  become  thick,  the  nose  broadens,  the  lips,  the  ears 


102 


THE  CAUSES  OF  DISEASE 


and  the  everuls  enlarge,  the  hands  and  feet  become  big  and  clumsy, 
it  p  ogres    oVthe  malady  i.,  slow,  and  the  extract  of  the  pitu.tary 
Ldy'of  m.  benefit  to  the  patient.    The  extract  fron.  t-e  m  ernajd.ae 
•ind  nosterior  portions  of  the  pituitary  body  causes  a  rise  ot  bloo(l 
pl^ssure  sSar  to,  but  more  prolonged,  than  that  of  the  extract  of 
tK^  nrlmnal   iiiul  ill  addition,  induces  a  marked  polyuria. 
''D^tb^c     R^^^^^^^^^  to  the  secretion  of  the  Adrenal  and  of  the  Chroma^ 
SysteT-The  medulla  of  the  adrenal,  apparently  the  more  unporta.it 
StoTthe  organ,  is  related  embryologically  to  the  sympathetic  ganglia 
iCextract  of  it  adrenin)  leads  to  great  increase  in  blood  pressure;  it  ac  s 
di  ecSv  on  muscle,  .ven  if  the  nerve  endings  are  degenerate.1      Ihe 
eitr  u'  of  the  sympathetic  ganglia  has  the  same  effect  upon  Wood  press- 
ure and  the  effect  of  ailrenin  upon  a  part  is  identical  with  the  result  of 
sthm  la  ing  the  sympathetic  fibres  to  that  part.    Both  in  the  medulla 
of   he  adrenal  and  in  the  sympathetic  ganglia  is  to  be  »-•';!  ^"-l;- 
able  series  of  cells  of  sympathetic-nerve  origin,  the  chromaffin  cells 
to-eal   d  because  ..f  their  affinity  for  chrome  salts,  the  cells  taking 
on   a  strong  vellowish-brown   color   after  immersion   of   sections    n 
potassium  Wchromate.     The  indications  are  that  wherever  those  cells 
a  eTresent,  adrenin  or  a  body  having  like  effect  upon  the  arteriole 
Tal   .  p^^^^^^         Wc  use  the  term  adrenin  rather  than  adrenalin  or 
epiiephin  because  the  latter  are  names  of  proprietary  ^"^s  ances^^ 
'There  are  several  pathological  states  which,  acting  ^^^^^^^'^^ 
inrr  the  adrenal    give  rise  to  the  disease  known  as  Addison  s  disease, 
it^s^hlclle'd  by  great  physical  weakness,  feeble  heart  ac.on 
and  pulse,   nausea,   vomiting,  and  pigmentation  of  the  ='^"-      i»^ 
pigmentat  on  is  most  marked  upon  exposed  surfaces,  and  m  regions 
normaTlv  pigmented,  and  varies  from  a  yellowish  tint  to  a  deep  brown. 
Xcaseiu!  tuberculosis,  atrophy,  malignant  g-f^^;-. '-^^f  £; 
nnd  inflammatorv  changes  of  the  adrenal  may  produce  it,  and  it  has 
^eVbeeTkntn  to  exis?  where  the  adrenals  are  healthy  but  th^^  ^^ 
thetic  gangHa  diseased.     It  may  well  be  imagined  that  the  lack  ot 
Solli-presslre-raising  material  due  to  the  destruction  of  the  orga"^ 
accounts  for  the  cardiovascular  depression.     As  regards^  the  cortex 
rS  gland,  it  is  interesting  to  note  that  just  as  overdeye Opment 
of  the  glandular  portion  of  the  pituitary  body  is  found  associated  with 
acromegalv  and  increased  growth  of  skeletal  tissues,  so  there  are  severa 
ca  esCfi  record  in  which  hyperplasia  aiul  tumor  growth  of  the  axlrenal 
cortex  has  been  found  associated  with  excessive  and  premature  obes  tj 
precocious  muscularity  ("the  infant  Hercules"),  and  premature  virihty 
with  precocious  devel.)pment  of  the  external  organs  of  generation. 

Disturbances  Related  '..  Secretions  of  the  Testes  and  Ovj.nes.-it  is 
known  that  in  castrated  animals  the  secondary  sexual  characters  fail  to 
develop,  and  this  is  due,  in  the  male,  to  the  loss  of  large^.i.terstitial  ce  1. 
in  the  testes  and  of  their  internal  secretion;  there  are  hom<.logou.s  cells 
in  the  ovary,  although  the  proof  of  the  effect  of  their  secretion  is  by  no 
in  me  ova  j  ^  i  ..  ,.  .^^  p^g^ratwl  animals 

means  us  clear  as  in  ini  tii^c  oi  mc  nm".. 


THE  ENDOGENOUS  INTOXICATIONS 


103 


can  he  produceil  by  the  injection  of  the  ovarian  extracts.  Not  only 
do  interniil  secretions  of  the  testes  and  ovary  affect  sexual  maturity, 
but  tiiey  are  also  evidently  concerned  in  the  full  physical  development 
of  tiie  bod,\.  The  function  of  the  corpus  luteum  is  of  another  sort; 
the  secretion  of  the  interstitial  cells  that  lie  external  to  the  Graafian 
follicle  is  evidently  j)otent  to  stimulate  the  uterine  mucosa  to  respond 
to  the  presence  of  the  ovum  and  permit  its  fixation;  where  the  ovaries 
are  removed  after  the  fertilized  ova  are  set  free,  these  do  not  become 
adherent  in  the  uterus.  A  secretion  acting  in  this  way  is  a  good  example 
of  a  iiormone. 

Disturbances  Related  to  Various  Other  Internal  Secretions. —  The  Foetm 
and  the  Mavimary  Gland. — It  has  been  proved,  according  to  Starling  and 
("lay])oii,  that  the  hyDcrtrophy  of  the  mammary  gland  in  pregnancy 
is  due  to  the  intern..,  secretion,  so  to  speak,  of  the  foetus.  Watery 
extracts  of  rabbit  foetus  injected  into  a  virgin  rabbit  caused  in  a  few 
weeks  hypertrophy  of  the  mammary  gland  and  the  formation  of  a 
thin  fluid  secretion;  in  multiparous,  unimpregnated  rabbits  this  was 
true  milk.  To  disprove  the  supposed  effect  of  nervous  influences, 
a  nianmiary  gland  in  the  guinea-pig  was  transplanted  to  the  region 
of  the  ear,  where  it  underwent  hypertrophy  in  pregnancy,  and,  finally, 
produced  milk.  It  is  thought  that  the  substance  in  the  foetus  which 
does  this  acts  upon  the  mammary  gland  causing  anabolism  and  growth; 
wliiMi  the  child  is  born,  lactaii'»n  begins  because  this  substance  is  no 
longer  present,  and. the  cells  which  before,  under  its  influence,  mani- 
fested anabolism  and  growth,  in  its  absence  break  down  and  form  milk. 
Thus  lactation  is  apt  to  cease  with  the  onset  of  a  new  pregnancy. 

Doubt  has  recently  been  thrown  upon  these  observations,  other 
observers  associating  the  growth  and  activity  of  the  mammary  gland 
once  more  with  the  corpus  luteum  of  pregnancy. 

Disturbances  Related  to  Secretions  in  the  Intestinal  Tract. — It  is  but 

icceiitly  that  we  have  discovered  how  intricate  a  system  of  internal 

icretioiis  exists  in  the  alimentary  tract,  and  we  shall  rather  try  to 

iinlicate  what  these  are  than  to  deal  with  their  derangements.     The 

H  id  contents  of  the  stomach  passing  into  the  duodenum  cause  an 

iiH  rcase  in  the  flow  of  pancreatic  juice;  this  hapi)ens  not  because  of 

n  Ilex  nervous  stimuli,  but  l)ecause  of  a  chemical  suir-<tance  which  is 

1 1  reted  by  the  duodenum  and  carried  by  the  blood  to  the  pancreas. 

i!  till'  mucosa  of  the  ducMlenum  is  scrajjcd  ott"  and  an  extract  made 

!  it  with  iiydrochloric  acid  added,  this  extract,  which  has  been  called 

■cretin,  if  injected  into  the  blood  of  a  mammal,  causes  an  abundant 

'   rction  of  pancreatic  juice.     In  a  somewhat  similar  way  the  secre- 

"!i  of  pyloric  glands  stimulates  certain  glands  in  the  cardiac  portion 

the  stomach;  these  instances  enable  us  to  surmise  that  not  only 

-  nervous  mechanism  stimulate  the  flow  of  digestive  juices,  shown 

tlie  mouth  "watering"  at  the  sight  or  smell  of  food,  but  also  that 

re  exists  a  series  of  secretions  developed  by  the  mucosa  of  one  part 

'  r  aiiotiier,  each  of  which  secretions  can,  if  absorbed  by  the  blood. 


Bfsn 


Ii  '. 


n 


III 


J04  THE  CAUSES  OF  DISEASE 

mmmmm 

S.:  manv  <asos  ..f  diabetes  that  are  n.>t  as  vet  at  all  exphcable. 

of  suhstratunr,  (-')  by  ncrmal  secretion  w.th  ^^^"^l «^^  "^^ 

I  ri>  hv  ■ilweiue  or  .liniiinitioii  of  the  hormone  without  wUitn  ine 
and  t.i)  b\  aDsnue  or  "  ""  ,     ,    ;  i,^  ,,1  the  organ 

that  m  an  ^""i  '^    j.    ,     ,    ^  f^.,,.  ..^.^rs  is  inihcatiiiK  that 

Uiel^'Sn  ^    -      W  lu: h  t  llidy  depen.ient  upon  t^.e  interaction 

;\):'s:c?eti:;;;s  of  tm.  duc.less  .lands;  that.  ..a  -r^aiii^ex^nt^^ 

but  thev  cert;:i^;iy  suLp.-rt  the  view  tliat  there  is  much  interdepe.ulence 

'^N^elllSateTproducts   of   Katabolism.- Intoxications   may   be 

,  JeM  h™e  in  Uvo  uavs:  either  the  excretory  organs,  being  diseased, 

:  Uo      m    ate  pro.luctsof  katabolism  or  even  if  the  secretory  organs 


THE  ENDOGENOUS  INTOXICATIONS 


10') 


eliminate,  there  may  he  resorption  of  tlie  excreted  material  owing  to 
ohstruetion  in  the  (hicts. 

The  Resorption  of  Excretions. — There  is  a  normal  resorption  of 
excreted  material  constantly  going  on  in  the  hody;  the  feces  solidify 
in  the  lower  howel  because  of  resorption  of  fluid;  the  increase  in  solids 
in  gall-hladder  hile  over  that  of  hei)atic-<luct  bile  indicates  absorption, 
while  some  physiologists  hold  that  urinary  water  is  reabsorbed  as  it 
passes  <h)wn  the  tubule;  this  suggests  that  there  are  many  series  of  cells 
which  work  in  two  directions,  that  is,  which  excrete  in  one  direction, 
and  ibsorb  in  the  reverse  direction.  \n  example  of  this  resorption  to  a 
serious  degree  is  found  in  ol)structive  jaundice;  here  the  bile  is  not  dis- 
charged, and  is  re-absorbed  by  the  lymphatics  and  the  blood.  A<  com- 
panying  such  jaundice  are  certain  cerebral  symptoms,  slowed  pulse, 
itching  of  the  skin,  lessened  coagulability  (»f  the  blood,  and  a  tendency 
to  hemorrhage.  Some  of  these  symj)toms  can  be  set  up  by  the  experi- 
mental injection  of  bile  salts,  although  normally  these  bile  salts  are 
re-absorbed  in  the  alimentary  tract,  whence,  however,  they  are  carried 
once  more  to  the  liver  by  the  proper  channel.  It  is  the  resorption 
at  the  wrong  place  of  such  an  excretion  as  the  bile  salts  that  causes 
the  disturbance,  rather  than  thei-  deleterious  nature,  per  ne.  The 
siinie  statement  holds  ivith  regard  to  the  pancreatic  juice,  which, 
if  rc-altsorbed  by  reason  of  the  obstruction  of  the  pancreatic  duct, 
can  set  up  pancn  ititis;  while,  if  bile  be  absorbed  by  the  pancreas 
troin  a  blockage  of  the  .\mpulla  of  \'ater  by  a  calculus,  a  yet  more 
-<\(Te  pancreatitis  may  ensue. 

Certain  cases  of  uremia  are  to  be  viewed  in  the  same  way.  I'remia 
may  be  due  to  renal  incompetency,  where  dangerous  constituents 
tail  to  be  abstracted  from  the  blood,  but  in  other  cases,  the  kidneys 
prrfonn  their  part,  but  the  ureter  or  the  uretiira  is  Idocked,  and  the 
urinary  epithelium  passes  back  into  the  blood  materials  from  which 
it  had  i)revioiisly  freed  the  blood.  What  the  substance  or  substances 
"ia>  be  that  cause  uremia  is  yet  unknown,  though  many  different 
I'Mc-  have  been  suggested. 

Disintegrative  Intoxications.— Autolysis. —  This  is  the  process  of  self- 

liHiittgration   that  tissues  undergo;  if,  for  example,   liver  tissue  be 

n  iiiiivcd  from  the  body  and  protecteil  ''•nm  septic  infection,  it  becomes 

"tt,  by  reason  of  enzyme  actions,  the  ,  .ost  important  of  which  is  that 

M  which  breaks  up  jjroteids.     To  illustrate  this,  on"  may  take  the  fol- 

ing  figures  (Wells):  a  liver  in  which  only  otie-tenth  of  the  nitrf)gen 

^  ill  a  soluble  form,  after  being  kept  twenty-two  days  aseptically, 

'aiiied    ix-tenths  of  its  nitrogen  in  a  soluble  form.     The  enzymes 

ii  li  bring  ai)out  this  change  are  elaborated  within  the  cells  them- 

1  ■',  and  all  soft  tissues  behave  in  this  way.  the  liver  and  renal  cortex 

"iig  the  most  active,  the  brain  substance  and  skin  among  the  least 

Autolysis  occurs  most  readily  in  a  slightly  acid  medium  and  at 

nipcrature  slightly  higher  than  that  of  the  body.     The  tissues  are 

rally  alkaline  in  reaction,  and  the  process  begins  only  when  this 


-f^'J^"^^.^"^' 


"..JT    ''.MSM..) 


ICG 


THE  CAUSES  OF  DISEASE 


[« 


p: 


alkalinity  has  boeii  neutralized  by  the  product.....  of  carbon  d.oxide 
and  or,L.ic  acids,  such  as  lactic  a..d  l>utyr  c,  wh.ch  are    or.ned  m 
dying  tissues.     This  process  of  autolysis  takes   place  ...   the    hv.ng 
organism.     Thus,  if  a  piece  of  liver  have  .ts  blood  ^«PP'y  f^^  f ' 
autolysis  will   ocur  in  the  n.ost  ,     ,tral   parts    but  ..ot   "?  the  per- 
ipheral because  the  alkaline  lymph  d.tf uses  ...to  th.s  part  of  ,t.     1  here 
is.  however,  an  exception  eve.i  to  this,  viz.,  wherever  leukocytes  gam 
entrance  i.i  large  numbers.     Leukocytes  possess  enzymes,  the  leuko- 
proteases.  which  act  most  powerfully  upon  the  leukocytes  themselves, 
but  once  liberated  act  also  upon  other  tissues.      Ih.s  explains  the 
softening  of  septic  h.farcts,  and  of  the  outer  zone  of  simple  infarcts, 
into  which  areas  great  numbers  of  leukocytes  migrate;  it  explains  also 
the  softening  and  absorption  of  the  exudate  in  a  p.ieumomc  lung. 
The  softening  of  a  tissue  by  the  effect  of  this  leukocytic  e.izyme  is 
called  heterolysis.  as  opposed  to  autolysis,  where  the  ce Us  themselves 
supplv  the  enzvme.    But,  to  prevent  this  universal  heterolysis  wherever 
there'are  leukocvtes,  there  is  an  antibody  m  blo,Ml  serum  which  tends 
to  neutralize  the  enzyme  of  the  leukocytes,  provided  these  be  not 
present  in  overwhelming  numbers  (Opie).  „         ,      ,        . 

Autolysis  is  seen  in  the  liver  in  cases  of  acute  yellow  atrophy,  phos- 
phorus and  arse.iic  poisoning,  chloroform  poiso.ii.ig.  and  in  the  group 
of  cases  characterized  by  pernicious  vomiting  (oftenest  cases  ot  prtg- 
nancv)  In  these  the  end-products  found  in  autolysis  are  present, 
viz.,  leucin,  tyrosin,  etc.  The  operative  toxin  has  evidently  destroyed 
the  cells  without  destroying  their  ferments. 

There  is  a  partial  explanation  possible  at  th.s  point  of  gangrene 
as  it  occurs  in  diabetic  cases.  Acidosis,  as  it  is  called,  is  a  condition 
of  heightcMcd  aciditv  or  lessened  alkalinity  of  the  tissues,  with  the 
production  of  acet..nuria;  such  is  freciuently  present  in  diabetes,  and 
this  lessene<l  alkalinitv  permits  the  occurre.ice  ot  autolysis,  althougli 
the  gangrene  is  probably  precipitated  by  some  active  toxi.i. 

Autolvsis  is  able  to  cause  certain  disturbances  ot  body  mechamsm, 
which  can  be  classed  as  (1)  disturbances  due  to  liberatio.i  and  diffusion 
of  the  enzvmes,  and  (2)  disturbances  due  to  toxic  action  of  the  dittused 
products  of  aut..!vsis.  It  is  quite  likely  that  in  some  cases  l^th  actions 
are  at  work.  Albumosuria  is  an  indication  of  such  a  diffusion,  the 
albumoses  appearing'  in  the  urine  when  there  is  exte.isive  aggregation 
of  leukocvtes.  with  its  accompanying  heterolysis,  such  as  happens  m 
the  resolution  of  pneumonia  or  in  empyema;  albumoses  appear  also 
when  lar-e  tumors  undergo  softening  or  necrosis.  Fever,  too,  as  it 
occurs  in  infarcts,  it.ternal  hemorrhages,  burns  or  suppuratio...  is  an 
indication  of  the  libi  ration  of  intracellular  enzymes;  the  exper.menta 
production  of  fever  by  ferments  of  all  orders  injected  into  the  blood 
has  been  often  <le.nonstrated.  Rarely  the  production  by  autolysis  of 
acutely  toxic  substances  occurs.  Cholin  is  liberated  in  the  autolysis 
of  nerve  li..ues;  it  is  not  highly  toxic,  but  it  is  readily  converted  into 
neurin  which  is.     Cholin  has  been  found  in  the  cerebrospinal  fluid 


RB^BSEC 


THE  ENDOGENOUS  INTOXICATIONS  7 

of  cases  of  nerve  degeneration  and  softening,  i*nd  it  is  suggested  as 
the  cause  of  convulsions  and  other  serious  disturbances  that  happen 
in  these  eases.  (Mott.)  Perhaps  a  similar  formation  of  toxin  from  the 
disintegrated  c  lis  is  accountable  for  the  toxic  manifestations  seen  in 
cases  (>f  severe  superficial  burns. 

Impaired  Metabolism  as  a  Cause  of  Disease.— At  times  the  cells 
of  certain  organs  of  the  body  do  not  carry  out  the  process  of  metab- 
olism to  its  normal  termination,  and  discharge  substances  that  are 
toxic,  or,  through  deficient  oxidation,  there  may  accumulate  in  the 
system,  bodies  not  themselves  toxic,  but  obstructive  to  the  proper 
activity  of  the  tissues.  At  other  times,  although  metabolism  can 
scarcely  be  said  to  be  impaired,  yet  the  metabjlites  fail  to  be  excrete<l, 
and  by  their  accumulation  tend  t  ■  cause  disease. 

Gout. — Gout  is  a  condition  characterized  by  attacks  of  acute  arthritis 
and  other  constitutional  symptoms,  clinically,  by  the  excess  of  uric  acid 
in  the  blood,  and  anatomically,  by  the  deposit  of  sodium  biurate  in  the 
curtilages  and  elsc.vhere.  It  must  not  be  imagined  that  this  excess  of 
uric  acid  in  the  blood  is  the  cause  of  the  disease,  for  uric  acid  in  excess 
exists  in  the  blood  in  a  number  of  different  states  without  gout  being 
j)rcsent.  The  urates  are  inert  bodies,  and  the  most  that  can  be  said 
is  that  they  are  an  indicator;  that  is,  the  faulty  metabolism  which  pro- 
tluces  them  produces  also  substances  that  are  toxic.  These  substances 
we  do  not  know  with  any  exactness. 

Uric  acid  is  one  of  a  group  of  substances  called  purin  bodies,  of  a" 
of  which,  purin  (CiH4N4)  is  the  nucleus.    These  bodies  are  uric  acid, 
xanthin,  hypoxanthin,  guanin,  adenin,  and  so  on.     By  some  they  are 
termed  the  alloxuric  bodies,  and  (with  the  exception  of  uric  acid)  some- 
tinics  the  xanthin,  purin,  or  alloxuric  bases.    These  bodies  are  derived 
from  nuclein,  which  shows  that  they  originate  from  the  disintegra- 
tion of  nuclear  substance.    This  nuclear  substance  may  be  from  the 
t"o(i  (meats),  in  which  case  the  purins  are  exogenous,' or  it  may  be 
Ironi  the  nuclear  substance  of  the  tissue  cells  of  the  body,  in  which 
'•a>e  they  are  endogenous.    There  is  normally  a  certain  small  output  of 
< mlogenous  j)urin  Ixxlies  which  represents  the  natural  wear  and  tear 
"i  tissue.    The  muscles  are  constantly  putting  out  hypoxanthin,  and 
t  xcreise  increases  the  output  of  uric  acid,  suggesting  that  one  purin 
'■"ily  is  readily  converted  into  another  in  the  body,  as  happens  in 
'  ">.    If  the  pancreas  be  chopped  up  and  allowed  to  act  on  guanin, 
ean  c  invert  guanin  to  xanthin  by  means  of  a  ferment  which  has 
'     n  called  guanase.     Similarly,  adenin  can  be  converted  into  hypo- 
wiihin  by  the  adrenal,  the  thymus,  the  pancreas,  or  the  liver,  by  the 
•kmi  of  the  ferment  adenase.    The  different  glands,  in  fact,  contain 
tiients  or  groups  of  ferments;  and  in  this  series  a  ferment,  an  oxidase, 
oiind  in  the  lungs,  liver,  muscles,  and  spleen,  which  can  convert 
alloxuric  bases  into  uric  acid.    Yet  another  oxidase,  found  in  the 
le.Ns,  the  liver,  and  the  muscles,  can  oxidize  uric  acid  into  urea. 
'Ily,  or  perhaps  one  should  say  firstly,  there  is  in  cells  generally 


*  rE."«Pf*- 


108 


THE  CAVSES  OF  DISEASE 


a  nuclease  l.v  which  nudeoprcteins  are  disintegrate.!,  liberating  the 

^"step  J»v  step  the  foii..wing  process  can  be  seen  to  mcur:    (1)  nudeo- 
prcteins; exogenous  fron,  tocHlstufls,  or  endogenous  tn..n  the  ImkIv  cells 
acted  on  bv  L-lea.e,  yield  (2)  purin  bases,  wluch,  acted  on  ^y 'luana^e 
orllemm'   vidd  (:i)  xanthin  and  hyp..xanthu.    which,  acted  ..n  b> 
an  arXi  yield  (4)  uric  acid,  which,  actetl  on  by  an  o.^da.e,  yields 

^""Thm-  are  ..ther  much  more  important  sources  of  urea;  but  this 
will  indicate  the  variations  in  the  amount  of  uric  acid  that  may  be 
derivxMl  from  the  same  diet,  and  the  importance  of  the  action  of  certain 
ferments  that  are  constantly  present  in  the  body.  «    *    ^t 

t  is  necessary  to  know,  m..re  fully  than  we  .lo  the  toxic  effects  of 
the  purin  bases',  for  they  are  toxic,  and  it  is  perhaps  the  purin  bases 
tat  are  responsible  for  gout.  Gout,  therefore,  is  probably  the  outcome 
of  iu.„ficient  oxidation,  wherd.y  the  precursors  of  uric  acul  and 
similar  bodies,  are  not  fully  oxidized,  and  by  their  accumulation 
anT  their  toxidtv.  set  up  morbi.l  changes;  and  the  uric  ac-id  formed 
L  i^i  its  turn  imperfectly  oxidized,  and  accumulates;  this  dimimshed 
oxidation  b  dne  to  a   constitutional   deficiency  of  oxidases,  inherited  or 

"'cystiluria.-The  appearance  of  cystin  in  the  urine  is  an  unimportant 
matter,  save  that  it  may  lead  to  calculus  formation;  but  it  is  worthy 
Tnote  at  this  point,  as  somewhat  paralld  to  gout.  It  tends^  to  be  a 
familial  disease,  characterized  by  the  appearance  ot  cystin  m  the  urine 
(Tstin  is  a  sulphur- containing  amino-acid.  and  the  evidence  seems  to 
show  that  it  arises  from  an  abnormal  disintegration  or  conversion  of 
the  sulphur-containing  part  of  the  protein  molecule. 

Alkaptonuria.-This  comlition,  in  which  the  unne  turns  dark  on 
exn(,sure  t..  the  air,  is  due  to  the  absence  or  deficiency  ot  a  specific 
oxidase  with  the  rcsul.  that  final  ,.xi<lation  of  the  aromatic  constituents 
of  the  protein  molecule  is  imperfect.    It,  again,  is  unimportant  clinically. 
Obesity.-The  accumulation  of  fat  in  the  tissues  is  n..t  a  toxic  mani- 
festation, but  follows  an  incomplete  oxidation  of  the  foodstuffs;  wHen  it 
brings  about  impairment  of  locomotion,  the  oxidation  process  becon^^-s 
vet  more  incomplete,  and  the  ill  is  cumulative.     The  normal  fate  of  fat 
in  the  bodv  is  lo  be  burnt  up,  yidding  ultimately  carbon  dioxide  and 
water,  and  a  fixed  amount  of  heat  and  energy;  in  obesif  fat  is  stored 
up  to  such  a  degree  that :«  per  cent,  of  the  total  ^^T.ght  1  as  been  found 
to  be  fat.    This  state  of  obesity  is  due  either  to  (1    excessive  absorp- 
tion of  food,  either  fats  or  substances,  like  carbohydrates  vh.,se  kata- 
hnisn,  vidds   fats,  or  to  (2)  inadequate   combustion  ot   the  fats  so 
acquired.    .\  given  case  of  obesity  may  be  due  to  both;  but  in  those 
eases  of  obesitv  which  show  anemia,  deficiency  of  hemoglobin  and 
....rpusdes,  it  seems  likdy  that  defident  oxidation  is  to  blame. 

In  the  plethoric,  obese  man.  who  has  no  such  deficiency,  the  explana- 
tion is  dther  overeating  or  an  hereditary  tendency  to  store  up  fat  upon 


THE  ESDOdESOUH  INTOXICATIOSS 


109 


a  normal  diet;  such  an  hereditary  tendency  is  often  combined  with 
jioutiness,  and  just  as  the  goutiness  means  imperfect  oxidation  of  one 
group  of  the  products  of  metabolism,  the  proteins,  so  the  obesity  may 
mean  imperfect  oxidation  of  another  group,  the  fats. 

Acidosis,  Acetonuria,  etc.— The  group  of  cases  which  how  lessene<l 
alkalinity  of  the  blood,  and  the  ;  cumulation  of  acetone  and  the  acetone 
bodies  ((i'-oxybutyric  and  diacetic  acids)  in  the  blood,  is  characterized, 
in  general,  by  grave  intoxication,  air  hunger  and  nervous  symptoms, 
U-ading  even  to  coma  and  death.  We  cannot  as  yet  say  definitely  what 
is  the  origin  of  these  bwlies,  whether  from  the  amino-acids  of  the  pro- 
tein molecule,  from  the  fatty  acids  or  from  the  carbohydrates;  perhaps 
in  different  diseases,  the  source  may  difft  for  acetone  and  the  acetone 
l)odies  appear  in  diabetes,  in  hyperpyrexia,  in  wasting  diseases,  in 
cancer,  and  in  starvation;  carbohydrate  star\ation  seems  to  be  a  con- 
stant factor,  whether  this  arise  from  actual  lack  of  carbohydrates  or 
from  impaired  ability  of  the  bmly  to  use  what  it  does  receive. 

The  accumulation  of  ,J-oxybutyric  and  diacetic  acids  in  the  blood 
of  diabetics  seems  responsible  for  the  main  symptoms  of  diabetic  coma, 
for  herbivorous  animals  to  which  they  are  administered  develop  the 
same  group  of  symptoms— the  blood  is  less  alkaline,  they  are  stuporous, 
(lyspiKric,  the  blood  is  bright  red  and  contains  less  carbon  dioxide 
than  normal.  If  alkalies  be  given  the  symptoms  pass  off,  just  as  may 
occur  clinically  in  diabetic  coma.  The  explanation  is  that  normally 
the  alkalies  of  the  blood  take  up  carbon  dioxide  from  the  tissues,  carry 
it  to  the  lungs,  where  by  the  help  of  the  oxidase  present,  the  carbon 
dioxide  is  split  .>ff,  and  the  salt,  once  more  basic,  is  prepared  to  take  up 
more  carbon  dioxide  from  the  tissues.  Where  there  is  excess  of  acids 
in  the  blooil  these  combine  with  the  basic  salts,  and  as  a  result  the 
ciirhon  dioxide  remains  in  the  tissues,  causing  symptoms  of  asphyxia. 
Before  leaving  this  subject,  it  may  be  recalled  to  the  reader's  mind 
tliat  this  condition  of  acidosis  seems  to  underlie  the  disturbances 
iiiund  not  only  in  diabetic  coma,  in  certain  cachectic  diseases,  and 
ill  starvation,  but  also  in  che  pernicious  vomiting  of  pregnancy,  the 
(Nclic  vomiting  of  children,  chloroform  poisoning,  and  certain  other 
less  common  states  where  grave  hepatic  disturbance  has  been  deter- 
mined; at  the  present  time  we  can  do  no  more  than  state  the 
"t)stTvation. 

Dyspnoea  and  Asphyxia. — These  symptoms,  it  will  be  seen,  depend 
upon  acidosis.  It  was  for  a  long  time  debated  whether  they  were 
<  iiiiscd  by  deficiency  of  oxygen  or  excess  of  carbon  dioxide,  and  the 
Itcision  is  m  favor  of  the  latter.  The  tension  of  oxygen  in  the  inspired 
Mir  may  be  reduced  from  20  to  8  per  cent,  without  inducing  dyspnoea,  but 
ill!  increase  of  tension  of  0.5  per  cent,  of  carbon  dioxide  in  the  inspired 
air  and  so  in  the  blood,  leads  to  such  increased  activity  of  respiration 
that  the  volume  of  inspired  air  is  doubled.  Be  it  noted  that  the  increase 
i-;  not  in  the  amount  of  carbon  dioxide  in  the  blood,  but  in  the  tension 
of  free  carbon  dioxide  in  it;  for  in  diabetic  coma,  as  has  been  said,  acids 


110 


THE  CAUSES  OF  DISEASE 


combine  with  the  alkaUes  present  in  the  hloocl  plasma  an.l  less  carbon 
dioxide  is  actually  taken  up;  but  it  st.ll  diffuses  in  the  bhuKl,  and  is 
present  in  a  free  state,  gh  ing  rise  to  the  asphyxia. 

Eclamp8ia.-There  is  a   most  grave  conditu.n   which   occasionally 
shows  itself  during;  the  last  few  .lays  ..f  pre^M.aney  or  in  the  few  hours 
immiatelv  fc.llowin^'  parturition.     It  apjK-ars  in  the  form  of  con- 
X  rollowed  by  ioma.   and   frequently  is  fata  .     Postmortem 
examh  ation  shows  that  there  are  two  orders  of  cases;  m  the  one  there 
"extreme  degeneration  of  the  ki.lneys.  in  the  other,  the  Irun    of  the 
Maucv  is  seen  to  have  fallen  up.m  the  liver,  which  exhibits  areas 
of  degeneration  even  to  complete  necrosis  of  the  parenchyma  ot  the 
organ      The  condition  is  essentially  associated  with  childbearing.  is 
,„,t  of  infectious  nature,  but  has  all  the  ear-marks  of  a  grave  intoxica- 
tion   but  as  to  what  is  the  exact  nature  of  the  intoxication,  we  are 
still' whoUv  in  the  dark.    While  some  attribute  ,t  to  the  foetus,  others 
bring  (inadequate)  evidence  that  the  toxic  material  (originates  from  the 
placenta.     Others,  again,  ascribe  it  to  want  of  balance  between  the 
internal  secretions  of  the  maternal  organism.     We  are  not,  therefore, 
in  a  position  to  classify  properly  the  ccmdition. 

Ptomaine8.-These  form  a  large  class  of  substances  obtained  from 
the  decomposition  of  animal  matter;  they  are  the  results,  although 
not  the  ultimate  results,  of  the  disintegration  of  proteins,  for  if  the 
decomposition  be  continued  beyond  a  certain  time  the  Ptomauj 
diminish  in  amount,  givins  place  to  simpler  s"b«tances.     The  wdl- 
known  ptomaines  are  methylamin.  di-  and  tmnetliylamm.  chohn,  neunn 
and  muscarin.    While  some  of  them  are  non-toxic,  others  are  intensely 
toxic     It  is  possible  that  the  symptoms  of  constipatu.n  may  be  due 
to  absorption  of  small  quantities  of  these  toxic  ptomaines  from  fecal 
matter  fermented  by  the  agency  of  bacteria;  bacteria  are  "ecessary, 
for  these  substances  have   never  yet  been  obtained   from  foodstuffs 
without  the  action  of  bacteria.    The  same  holds  true  for  a  group  "f 
substances  of  a  lower  toxicity  than  the  last,  which  are  formed  from 
carbohvdrates  bv  the  action  of  bacteria;  these  are  the  organic  acids- 
formic,"  butvric,' lactic,  etc.,  and  the  interesting  point  al«ut  these  is 
that  if  thev  are  repeatedly  administered,  they  cause  disturbance  ot 
a  chrc.nic  tvpe  such  as  ,  irrhosis  of  the  liver.    This  is  evidently  not  the 
sole  cause  c.f  cirrhosis  of  the  liver,  because  it  can  arise  from  some  such 
circumstance  as  this;  the  obstruction  may  tend  to  increased  bacterial 
activitv  in  the  intestine,  which  irritates  the  mucosa    permitting  to 
enter  the  portal  svsten:  bacteria  of  low  virulence,  whose  endotoxins 
are  liberated,  causing  hemolysis  and  irritation  of  the  liver.     From  what 
has  been  said,  it  will  be  gathered  that  these  intoxicants-ptomaines 
and  indol  and  such  others— are  rather  exogenous  than  endogenous. 


BODILY  STATES  AS  CAUSES  OF  DISEASE 


111 


INTOXICATIONS  NOT  PURELY  EXOGENOUS  OR  ENDOGENOUS 

Oastro-intestinal  Intoxications.  Constipation.—It  is  a  common  obser- 
vation that  constipation,  in  a  person  whoso  habits  are  regular,  induces 
a  tVeling  of  lessened  well-being,  and  in  some,  actual  headache  or  malaise. 
What  is  the  actual  toxin  or  toxins  at  work  we  cannot  yet  say.  In  acute 
obstruction  of  the  alimentary  tract,  where  vomiting,  weakness,  or 
colIai)se  is  present,  we  are  in  a  position  to  be  more  explicit,  although 
not  dogmatic.  Obstruction  of  the  upper  bowel  is  more  grave  than  that 
of  the  lower,  and  the  possible  causes  of  this  severe  intoxication  are 
two:  either  (1)  the  blockage  lets  unusual  bacteria  bring  about  abnor- 
mal fermentation,  or  the  bacteria  produce  their  own  toxins,  or  (2) 
tliere  are  elaborated  in  the  stomach  toxic  materials,  .nich  are  in  normal 
digestion  modified  lower  down.  Both  these  may  be  true,  although 
the  better  evidfence  is  in  favor  of  the  former;  obstruction  does  permit 
increase  of  virulence  and  increaseil  multiplication  of  the  bacteria  above 
it,  though  it  has  to  be  admitted  that  the  toxins  of  intestinal  bacteria 
grown  outside  the  body  do  not  i)roduce  the  marked  symptoms  found 
in  obstruction.  It  is  true  that  one  group  of  toxins— the  indol  group — 
<l(ies  show  some  toxic  power,  but  in  the  intestine  it  is  as  likely  to  be  an 
indicator  of  a  high  degree  of  intestinal  putrefaction  as  to  be  the  efficient 
t(p\in  itself.  Indol,  however,  if  ingested,  sets  up  irritability,  mental 
liuhiess,  and  headache;  it  can  be  formed  in  the  test  tube  from  peptone 
liy  liacillus  co/i— the  commonest  inhabitant  of  the  intestine— and  is 
tmiiid  in  the  urine,  in  small  quantity,  it  is  true,  in  obstruction.  One 
may  sum  up  by  saying  that  part,  but  not  all,  of  the  toxic  manifesta- 
tiuiis  of  obstruction,  are  probably  due  to  indol,  skatol,  and  related 
'!<•(•( )mposition  products  of  proteins. 


th 


BODHT  STATES  AS  DIRECT  AND  PREDISPOSING  CAUSES  OF 

DISEASE 

Overstrain.    Overstrain  and  fatigue  are  the  results  of  work,  with 

<■  difierence  that  while  fatigue  is  the  natural,  physiological  sequel 

iietivity,  overstrain  goes  a  step  farther  and  indicates  an  abnormal 

,'ree  of  fatigue  or  a  pathological  effect  wrought  by  activity;  exhaus- 

'II  goes  farther  yet,  and  implies  overstrain  carried  to  suoh  a  point 

It  continued  activity  is  impossible  unless  a  period  of  rest  intervene. 

l-vcryone  knows  by  experience  that  fatigue  is  a  natural  consequence 

•'irk  and  demands  rest;  if  adequate  rest  be  obtained,  fatigue  dis- 

■e.'irs,  and  the  worker  is  left  better  able  to  work  than  before— the 

lit  being  that  in  course  of  time  that  maximum  stato  of  ability  to 

k  is  reached  in  which  we  term  the  worker  or  the  atlia  te  "trained." 

!i'nve\er,  the  rest  be  not  adequate,  or  if  work  be  carried  to  such 

'  vteiit  that  the  fatigue  is  excessive,  or  if  the  work  be  of  the  nature 

II 'lent  effort— the  return  to  the  normal  is  secured  onlyj[after  a  rest 


J, 2  rilh:  CMSHS  Of  DISEASE 

g„t  ••ov.rstra.n.       turtlu-r,  tlu-    .r-     r      u  ^,^^_  ^^^^^^, 

the  .m-rstrai..  is  tlu-  worst-  t..r  it.  .s  '  '^  r"  '^,^.,,,,^,,a.  Practicaiiy. 
,,„t  is  loss  .apahU-  of  ^l"'"''".'*;,,  ;,:::;'  ri.vsic.ian.  and  an 
this  is  lK.,-on.in^  . la.ly  o»  ""'"y^;''';,  ,.,,.,.  stn-ss-  an.l  rest  is 
understanding  of  t  -  I'^^^.I--'       ''•)^^^^  „,,r,  the  nervous 

.sse.Uial  to  him.    \^'';'»''\'^  ^^'"'^^      'V    .  t     .     'tlu-r  ease,  if  the  w,.rk 

or  the  nn.seular  •-•'■'"'■-'""":;  ^/u/ni^.tl  e  luulv  <l«-s  -t  ^^^^^^'' 
,lHnee.iualinnnUsot«MurK    thefoHltaM  n^^^^  .  ^^^.^.^^^^^^^^ 

hecans'-  the  n.er^^y  that  the  '->>  '  ;;;;^^j,i  ^  tre  is  a  .laily  .Iraft; 
to  which  there  is  a  .la.ly  .nenme  ""  /" '"  ^  ';\'^,  .cc.n.e.  the  aeeount 
if  .lav  hy  day  the  a.n.mnt  'l>-»^^'\;'  ,*^Vl  ^^  ,,  will  equire  many 
.H.„ii,ishes.  an.l  a  sud.le,.  '7«'-^'  .^I'^o^'^.e  am..int  ..f  the 

aays  of  ineonu-  wrth  --'^^-^^  l^^'^  „^  ..ther  a-.alo^ies  i,,  the 
aeeount  is  restored.  II.  rta(ur  .a  '.'  r  .j  ij^ress  ,)n  if  we 
same  line  of  thought;  and  ^T^^^^./^f ;','-' student  to  rea.l  the 
r 'Tuest -S'  Er  :"  n£  whU-h  tellently  demonstrates  how 
^'"^^' Va  ;^;;;;;l'.tie  prmnple  is  iudicic^s  ina...ty.  .  ^^^^^^^, 

droppe.l  .lea.l  at  Athe..s  alter  P^^'^  ;;  ^^^^,,,,  „f  ,„m.cat- 
Thire  are  all  gra.lations  from  ^''•%*'';^';,  ,t'  ,  hIV  ">  n...  har.l  t<.  cateh 
i,„  hreathlessness  of  the  "^•">"""-  '^,;\^  /^sser  grades  ..f  superacute 
his  morni..K  train.  The  sympton..  ol  »  .^^^^^^  ^^^  ,,,„rt  n..t  l.ei.ig 
overstrain  seem  lar,ely  due  f.  c;ard.,K-  ';^^';  Jg;,^";,,,,,.  The  eases 
able  to  pass  on  the  hlood  as  rap.dl>  as  t  k  J^"     '^^  ''^     ;,,  ,,«,. 

"'  whieh  death  follows  ...tense  I-  ^  J     f  .^  pn^^^^^^^    «>f  muscular 
that  tl.m>  are  discharged  .nt..t^uW^^^^^^^^  ^^^^^^^^_   ^^^^   ,,^,^l^ 

activity,     (adayenc   "«»>     .  ,  T  Sa^^^^  The  acute 

vcous  hlood  fa.ls  to  eoagu  ate     »  e    a,,  a  ne  ^^^  ^^^^^^  ^  ^^^^^ 

.legree  of  ..verstra.n  may  he  excited       smn  ,5^^,,    ,,^   ],,,, 

anorexia,  fever,  pa.n  in  the  l.ml.s.  am    is  re  _^^  ^^^.^^_.^, 

,onger-<-o,.tim.ed.  but  less  extreme  c^w^^^  ^^^  ^,,^^  p, 

„„,  pianists-  c-ramp.  "'".fj;^",';'  general  manifestations  of  dis- 

;;;;l.r  fn:  reSrof  ^h:\.;iUe.es  in  th^r  attempts  to 

kc>ep  accommodation  i)erfect.  TH<:ease  —It  is  long  known  to 

>  Ov.«.„,  i.  .ho  „h,.i,.,l  ™..  ove,«,»,  .he  bodily  s,...  p»i«<«d  by  it. 


BODILY  STATES  AS  CAVSES  OF  DISEASE 


u:\ 


more  lial)lc  to  infection,  that  hard  work,  loiij?  hours,  and  inadequate 
rc^t  make  men  more  lial)le  than  normal  to  aciiti-  diseases,  such  as 
iiifhienza  and  pneumonia.  If  resting  animals  anti  animals  under- 
KuiiiK  forced  lahor  are  subjected  to  the  same  doses  of  bacterial  cultures, 
tlie  resting  animals  resist  much  the  better;  if  into  any  such  ammal, 
aloMK  with  the  culture,  lactic  acid  be  intrtKluced,  the  bacteria  grow 
the  ni.)re  readily;  this  is  interprete<l  to  mean  that  the  acid  produced 
by  the  muscular  activity  of  the  exhausted  animal  assists  the  growth  of 
ctrtnin  bacteria  in  the  tissues. 

In  a  wav  entirely  local,  also,  overstress  renders  the  organ  concerned 
sn.riallv  liable  to  disease,  and  this  is  true  not  only  of  overstress,  but 
also  of  stress;  in  the  foetus,  the  right  heart  bears  the  brunt  of  the  circu- 
latory work,  and  in  the  foetus  cardiac  disease  is  right-sided;  subsequent 
to  bi'rth,  the  stress  on  the  left  side  of  the  heart  is  greater,  and  iieart 
,liscasc  tends  to  be  left-sided.  It  is  notable  in  this  connection,  too, 
that  vegetations  grow  on  the  heart  valves  as  a  result  of  infection  plus 
stress;  the  entire  surface  of  the  valve  is  exposed  to  the  insult  of  the 
iiilVction,  but  the  entire  surface  of  the  valve  does  not  develop  vegeta- 
tions- the  area  near  the  valve  edge  where  one  valve  strikes  the  other 
ii,  closing  is  the  part  that  is  exposed  to  both  the  insult  of  infection  and 
ih,.  insult  of  stress,  and  here  it  is  that  the  vegetations  develop. 

I'he  last-named  principle  works  in  both  directions,  so  that  not  only 
;ir(  "strained"  organs,  or  parts  thereof,  liable  to  infection  and  other 
.laiiiiigi',  but  infected  or  damaged  areas  are  more  liable  to  overstrain 
than  heaithv  ones,  or,  stated  otherwise,  what  is  merely  stress  for  healthy 
li.Mic  is  overstress  for  damaged  tissue.  It  is  the  subjects  of  chrome 
intoxications,  such  as  syphilis  or  alcohol,  in  whom  the  ordinary  work 
of  ihc  circulation  produces  aneurysmal  and  other  evidences  of  vascular 
iK.crstrain. 

Muscular  Fatigue  and  Overstrain.— Muscular  fatigue  has  been  con- 

-hlcrcd  bv  some  as  fatigue  of  the  muscle  fibre;  by  others,  as  fatigue 

of  tli(>  nerves  concerned;  it  is  one  or  the  other  or  both.    The  muscle 

ii-dl'  can  l)e  fatigued  by  direct  stimulation,  because  the  substances 

!.ro,luccd  bv  contraction  inhibit  further  activity;  when  the  nervous 

I  i.rliaiiism  is  considered  we  cannot   experimentally  fatigue  the  con- 

!  h  tiiii;  iixoiie;  nor  can  we  fatigue  perceptibly  the  reflex  centres  m  the 

..1,  htit  what  we  do  observe  is  this:  if  a  reflex  centre  for  a  particular 

I  !M  If  be  selected,  a  centre  that  is  amenable  to  influences  from  several 

..rent  tracts,  and  we  stimulate  one  of  these  tracts,  we  produce  in 

'  !i,c  the  phenomenon  that  the  muscle  no  longer  responds;  if,  now, 

tlur  afferent  tract  be  employed,  the  muscle  at  once  responds. 

'    >liows  that  the  muscle  itself  is  not  exhausted,  nor  is  the  axone 

m.tcd;  what  is  exhausted  is  the  synapse,  the  junction  between  the 

.  M  lit  nerve  tract  and  the  nerve  cell  of  the  reflex  centre;  these  two 

.  parts  of  different  neurones.    Let  us  here  digress  to  give  a  "  working 

.."  of  tlie  connection  between  neurones.     One  nerve  cell  does  not 

1  'liy  join  another  n.^rve  cell,  but  we  may  say  that  it  is  in  contact  or 

8 


JJ4  Tilt:  r.tf.SA'.S  OF  DISEASE 

almost  i..  contact  wit!,  if.  t.rininal  Klaim-nts  of  ono  .-.•11  are  in  "nlmost 
c     tact''\vith  tlu-  .Un.irit...  of  uhoUut.  likr  tl..-    .ranc-  u-s  o   one    ree 
h    .r m  n«li..«  with  hut  not  actually  tonchinK  the  hranches  of  another; 
.  m  e^^i^     acr.,.>  ti,.   spu<-e  fn.n,  twi,'  to  tw.K.  when  they  are  .n  a 
"    e  of  "ah  .ust  eoMta.  ..••    Fatigue  of  a  nerve  eel   may  he  praetual  v 
t       «ht  of  as  a  shrinking,  hy  which  tl -  twjKsor  »'--^- ;>^  ;-;;- 
,lra«..  a'sav  fron.  the  ..ther.  so  that  wn|»"l^«'^  have  fa  ther  to  jump 
r    u  one  to  another  than  hefore.  an.l  .io  so  U-ss  rea.h  y;  .f  cells  are 
at  Lue.l    the  in.pulses  pass  poorly  he.ause  of  tins  withdrawal  from 
CO  frc     «'  h  sKh-p  we  may  supp..se  that  the  rested  .len.lr.tes  or  axones 
arf  ;xp;n.linK  oul  on.e  n.ore  to  a  p.-sition  of  almost  contact;  so    ha 
o    waking,  the  impulses  (or  thoughts  or  whatever  they  may  h      -ass 
^„.|iiv  on'c  nx.re.    Hevertin,'  to  the  spec.hc  example  we  are  c  ...k^- 
Inl'.  ie  uui>  iM.ap.u-  that  the  cnstant  stimulation  of  one  atferenc  t-act 

Fio.  3;) 


.,     re,„nK    u.-rv.-    .,11    «i.l.    luU-    r,„.,„l..l     nu.l-»-,    .h-wiim    .■hnHnru,,,     no,w.,rk      ll.o    Ni»-1 
.     I,'..  In    he  ,vtoDl«-in  (.leriv,-,l  from  tl„     nu.  l.ar    nmi.T.al.    uU.   large    and   prom.mnl;    B,  ex- 

;:ui:.H    nerve  VI :.    J,,,"  .,r,l..r.    » hrunk-n    ,rre« nuHeus,   chro.n.Uin    uetwork    .nd,.- 

„n,-.,  .N,s,l  1,.«1,..,  .1 u.M,..,l  in  si»-  .n,l  ,>„..rly  staining.      <A1.,r  (;u,tav  Mann) 

nuik.s  tlH>  processes  ..f  that  neurone  draw  away  till  the  impulse  no  longer 

rea.lilv  jumps  the  sap.mi<l  the  n.urone  noverniuK  the  muscle  is  no  longer 

stinniiated ;  the  state  of "  almost  contact"  is  lost  the    synapse   fatigued . 

when  a  new  neurone  is  used,  which  is  in  "almost  contact    with  the 

neurone  gov.Ti.ing  the  muscle,  the  impulse  passes  readily,  ami  the 

neurone  and  the  muscle  ropond.  ,     f  *•         c 

Fatigue  of  the  musrie  itself  appears  to  he  due  t..  the  formation  o 

products  of  muscular  activity- sarcolactic  aci.l,  carhonic  acul,  and 

others       These   suhstances   have  eirect  prohahly  also  on  the  nerve 

niechanisin;  and  tinallx ,  we  have  to  admit  that  nerve  cells  themselves 

are  capahle  of  organic  change  through  us«— that  even  the  process  (jt 

reasoning  tires- although  the  experimental  proof  is  not  to  he  ohtaine.l. 

Thi.  exhaustion  of  the  neurone  lia-^  heen  well  demonstrated  hy  Hodge 

and  others  hy  comparison  of  the  staining  power  of  nerve  cells  and  nuclei 

in  rest  and  after-prolonged  activity. 


■P.L  uaii 


wm» 


W^VP 


I'HKDISI'OSITIOX  AM)  SI  srKI'TlHILITY 


n:. 


Lack  of  Activity  and  Disuae  aa  Catuea  of  Diaeaaa.  lissiu-H  utrophy 
if  iiimscd,  niici  the  ntropli\  so  prixliicc'd  is  not  in  any  svusv  different  frorii 
the  atrophy  that  follows  ilitninutioii  of  l)lo<Mi  supply  to  u  part;  the 
most  that  can  he  said  is  that  tissues  in  activity  tend  to  have  a  ko«hI 
ciriiilation,  ade(|iiate  nourishment  and  prompt  removal  of  waste 
|»rodii(  ts.  All  this  is  lacking  in  muscle  wh.'se  nerve  supply  is  cut 
otf,  and  amid  these  various  coincident  circum?  inces  it  is  not  possible 
to  say  which  is  most  responsible.  A  won!  i  necessary  here  alwut 
so-called  trophic  nerves;  these  were  supposed  to  be  fibres  which  had 
special  Ko\ernance  over  the  nutrition  of  the  tissues;  but  the  atrophy 
or  other  deranKcment  of  tissues  separated  from  central  control  neefl 
not  be  due  to  the  section  of  trophic  nerves,  but  may  surely  arise  from 
liuk  of  properly  governed  activity,  from  consequent  inadequate  focnl 
Mipply  because  vasomotility  is  not  rightly  governe«i,  from  delayed 
ntn(  '.al  of  waste  priMlucts.  Since  perfect  health  of  tissue  depends 
upon  the  right  coiirdination  of  initrition,  vascular  supply  and  cell 
intivity,  it  seems  reasonable  to  suppose  that  the  lack  of  this  coordina- 
tion may  be  attended  by  actual  tissue  alterations  and  by  increased 
liability  to  infections. 


PREDISPOSITION   AND   SUSCEPTIBILITT 

Hy  these  terms  we  mean  an  abnormal  lial)ility  to  be  influenced  by 
si.nic  environing  factor,  whereby  a  morbid  state  is  set  up.  Living 
uii.ier  different  conditions,  it  has  come  about  that  no  two  of  us  respond 
in  exactly  the  same  way  to  thf  same  external  influence;  even  in  an 
"iiiividual,  different  tissues  resjx  nd  with  varying  degrees  of  reaction 
In  the  same  stimulus.  Sensitiveness  above  the  degree  that  is  usual 
i>  susceptibility  or  predisposition.  As  was  shown  earlier,  this  predis- 
I'l'Mtion  may  be  inherited  or  acquired. 

1 1. hcrited  predisposition  may  be  (o)  specific  or  ex  specie,  as  is  shown 
l'>  the  predisposition  of  cattle  to  pleuroi>neunionia,  dogs  to  distemper, 
iii.Mi  to  gonorrhoea  and  typhoid.  Or  i  may  be  (6)  racial.,  as  seen  in 
I'liropoans  and  yellow  fever,  Hebrews  ai.*:  diabetes,  or  it  may  be  (r) 
familial,  as  in  certain  exanthemata,  piUiiciilarly  neuroses  and  r>ut. 

it  IS  necessary  to  digress  at  this  po.Dt,  1.)  indicate  that  error  may 

•  I  il.\  occur  here.  A  family  may  rea'lv-  be  comparatively  immune  to 
I  I  Incase  because,  by  survival  of  the  fittest,  the  stronger  members  of 
'! «  fatnily  have,  by  virtue  of  some  characteristic,  been  able  to  resist 
1  'iis.ase  to  which  they  were  liable  and  have  been  enabled  to  hand 

•  '  fi  this  characteristic  strengthened.  But  where  a  disease  has  been 
'  I'  inic,  there  are  many  individuals  who  have  acquired,  in  an  unnoticed 
'  iiMT,  their  immunity.  They  have  had  unrecognizable  or  unrecog- 
!  ■  '1  !!!i!d  attacks  of  the  specific  disease  which  h.-ivc  siiflTiccd  to  protect 
''  •  ni.  Tins  is  seen  in  the  apparent  immunity  of  the  natives  of  manv 
'    :  itnes  to  malaria,  the  children  when  examined  having  the  malarial 


■■>■ 


J  J, J  77/ A'  CAISES  OF  DISEASE 

•     xu  •    11     A      V..V    iiiort'    tht'V  niav  only  Have  taken  in 

stimulate  them  t(.  build  up  an  immunity  to  the  disease. 

Ckssifi^tion.  --Predispositic.n  may  be  classifiec   aceording  to : 

?   Sex -The  female  I  exposed  to  a  series  of  disorders  connected 

anL^(to  tl^^nd  of  fir;[  year);  athrepsia,  various  forms  of  enteritis 
with  diarrhoea;  meningitis  ,•  wi^^rlo 

Childhood  -  Rickets,  measles,  scarlatina,  diphtheria. 

Srt-'i  1^W^«^^««-^'W"™^'«  (i"  female);  acute  rheumatism 
and  Snatic  heart  disease  (ten  to  fifteen) ;  typhoid ;  tuberci.losis 

irfllS     Typhoid  (twenty  to  twenty-five);  tuberculosis  (twenty  to 

^^''uiddle  lo<'-G..ut,  lithiasis,  and  chronic  Bright's  disease  (thirty- 
five  ontrd'  arteriosclerosis,  aneurysms  (thirty  to  fifty);  cancer  (forty 

*°oKfl«  -The  same  continue.1,  along  with  atrophic  conditions 

3  HaSit  of  Life  at  Different  Life  Periods.-In  the  years  of  infancy 
when^rowth  is  procecling  rapidly,  the  digestive  system  is  under  xno^t 
tress  Med  power  of  locomotion  prevents  much  exposure  to  nfec- 
tousdi  eases,  which  occur  at  a  later  time  when  the  child  ^^f^^^^fj 
S,  is  fellows-  the  age  of  work  produces  often  a  more  sedentary  hfe 
„  mo  e  cnifiuHl  and  often  less  well-ventilated  -"oundings  ( the 
nerio.1  of  tuberculosis);  with  increasing  age,  lessened  exercise  and  yet 
Ee  sedenarv  life  ten.l  to  constipation,  gallstone  fo^^^ion,  etc 

4  ^evlus  infection.  -Although  in  some  diseases  an  attack  con  er. 
immunity  there  are  others  in  which  there  remains  a  greater  liability 
to  as";  md  attack;  such  ar.  erysipelas,  furunculosis,  acute  rheumatism. 
Z  influenza  It  mav  be  that  the  germs  of  the  disease  are  not  destroyed 
and  hat  a  low  stat^  of  general  health  permits  them  to  flourish  once 
more  Not  onh"  this,  buc  an  attack  of  one  disease  is  frequently  followed 
ran  infc'etion  .>f  a  different  kind,  as  when  one  exanthem  is  imme- 
Hiatelv  followed  bv  another.  .  .  ,.  , 

t  Malnutrition.'  To  exemplify  h..w  malnutrition  .P- -P-  t^^ 
disease  it  is  necessarv  only  to  cite  the  severe  epulemics  of  infectious 
disease' ihat.  at  dilVer'ent  times,  have  followed  upon  famine  m  Russia. 

'"Se  ^ceSllliy  of  Particular  Tissues,     l^f-ence  is  ma.le  here  ijot 
to  the  susceptibility  ..f  an  area  that  is  injured  or  badly  nourished,  for 


I 


^ 


PREDISPOSITION  AND  SUSCEPTIBILITY 


117 


thih  has  1>«  (Ml  already  dealt  with,  hut  to  the  fact  that  certain  tissues  are 
prone  to  pirinit  the  growth  of  certain  infectious  agents.  The  channel 
of  entrance  has  something  to  do  with  this,  so  that  inhaled  germs  often 
attack  the  respiratory,  and  ingested  germs  the  digestive  tract.  In 
foci  that  are  clearly  secondary,  and  evidently  selective,  we  find  the 
tubercle  bacillus  growing  readily  in  the  pia-arachnoid,  but  infrequently 
in  the  brain;  infrequently  in  the  stomach,  and  often  in  the  small  intes- 
tine. Even  if  injected  into  the  blood  stream,  colon  bacilli  are  apt 
to  set  up  enteritis.  The  fact  of  the  susceptibility  of  special  tissues 
remains,  but  we  have  no  adequate  explanation  for  it.  Consideration 
of  these  data  brings  us  to  an  important  conclusion  that  an  injection 
does  not  involve  the  whole  body.  Coincidently  with  the  growth  of  the  specific 
lirrms  in  individual  organs,  there  tends  to  be  a  reaction  to  and  destruction 
of  the  same  in  other  parts.  We  find  typhoid  bacilli  in  a  patient  suffer- 
ing from  that  disease,  in  the  spleen,  liver,  skin,  and  kidneys,  but  with 
much  difficulty  in  many  other  organs;  yet  we  know  that  the  infection 
is  a  universal  one,  and  that  these  other  organs  have  their  chance  to 
i)t'Come  infected.  It  seems  that  in  susceptible  regions  the  bacteria 
are  winning,  and  in  others  losing  their  battle  with  the  tissues. 

Idiosyncrasy. — This  term  is  applied  to  the  exhibition  of  extreme 
susceptibility  to  the  influence  of  substances  that  are  not  hurtful,  and 
even  beneficial  to  the  average  of  people.  Strawberries,  shell  fish, 
certain  fish,  in  some  people  cause  urticaria  or  other  skin  eruption, 
headache,  and  in  fine,  indications  of  an  intoxication;  idiosyncrasy  to 
drugs  is  familiar  to  everj'  physician.  Hay  fever  is  an  idiosyncrasy 
to  one  or  more  particular  kinds  of  pollen;  and  the  presence  of  a  cat 
ill  the  room,  although  unseen  and  unthoughf  of,  produces  in  some 
lieople  a  state  of  nervous  apprehension,  explicable  by  some  unper- 
(cived  olfactory  impression;  these  as  yet  are  curious  facts  lacking 
explanation,  save  that  the  recent  study  of  the  phenomenon  of  anaphyl- 
axis has  introduced  us  to  a  possible  explanation  of  at  least  some  cases. 
I'lie  administration  of  minute  doses  of  protein  followed,  after  a  few 
ihiys,  by  larger  doses  of  the  same  protein,  results  in  a  general  systemic 
'li-turbance  resembling  that  seen  in  some  of  these  cases  of  idiosyn- 

I  riisy — malaise,  profound  depression,  coryza,  erythematous  and  other 
'  iiiptions  on  the  skin,  or  even  in  some  cases  severe  respiratory  distress 

I  an  asthmatic  type,  the  phenomena,  in  short,  of  "serum  sickness." 

I I  is  evident  that  the  system  may  develop  an  extraordinary  suscepti- 
'iiity  toward  one  or  another  protein,  by  the  exhibition  of  relatively 
I  unite  quantities  of  the  same.     The  food  idiosyncrasies,  hay  fever,  and 

'  lie  eases  of  asthma  seem  thus  to  come  into  line  with  serum  sickness 
i  iiiiaphylaxis  in  general. 


m 


CHAPTER     III 

THE  MORBID  AND  REACTIVE  PROCESSES  PROPER 
THE  LOCAL  REACTION   TO   IRRITATION-INFLAMMATION 

It  is  verv  necessan'  for  the  student  to  obtain  a  clear  understanding 
of  what  inflammation  is,  and  how  it  begins,  progresses  ancl  ends 
because  a  hirge  fraction  of  all  the  pathological  specimens  he  will  exer 
see  and  a  majority  of  the  clinical  cases  he  will  be  called  to  treat  involve 
n  some  way  his  process.  He  can  become  conversant  with  the  thousand 
specTl  cases  of  inflammation  only  by  knowing  that  the  same  general 
laws  underlie  them  all,  even  those  most  diverse  in  appearance. 

In  whatever  member  of  the  animal  kingdom  wx-  examine  it.  the 
response  to  an  irritation  is  similar;  if  we  scratch  the  tissue  of  an  inverte- 
brate with  a  needle,  certain  effects  are  produced;  if  we  scratch  the  skm 
fa  human  being  we  fin<l  effects  that  at  bottom  are  similar;  m  other 
words,  the  tissues  from  their  simplest  to  their  most  complex  type  have 
earned  onlv  one  way  to  behave  when  they  are  irritate.l  or  injured 
thJcomplei  b.,dv  has  more  ways  of  exhibiting  its  reac  ion  because  it 

IS  more  .lifferentiated  tissues,  but  the  process  we  see  in  the  simplest 
animal  we  fiiu'  also  in  the  most  complex  animal,  and  it  is  this  unit> 
that  makes  it  possible  for  us  to  construct  certain  rules  which  underlie 

everv  case  of  inflammation.  ...  •     j.-  ^u^t 

Infiammatkm  is  the  series  of  local  adaptive  changes  in  tissi-    that 
result  from  actual  or  from  referred  injury.    By  injury  we  mean  all  grades 
„f'  stimulus,  from  a  mere  irritation  which  only  quickens  the  activity 
the  cells   to  a  damage  which  kills  or  all  but  kills  them;   and  we 
sist  upon   ome  such  understanding  of  the  term  inflammation;  because 
S  ;.  who  work  in  a  special  fiel.l  are  apt  to  restrict  the  term,  and  here 
t  e  phvsician,  the  surgeon,  the  physiologist,  and  the  medical  student 
musrmeet  on  a  basis  common  to  all;  the  tissues  behave  after  the  same 
manner  whether  they  are  injured  by  the  aseptk-  knife  o   the  surgeon 
the  i)oison  of  the  Staphylococcus  aureus,  the  flame  or  the  frost,  and 
i    would  be  wrong  for  us  to  lay  <lown  restricti.ms  that  nature  has  indi- 
cated so  definitely  to  be  false.    There  are  those  who  say  that  inflamma- 
tion of  a  wound  occurs  only  when  infection  invades  it;  not  so,  the 
wound  itself  implies  inflammation;  and  this  broad  view  of  the  case 
having  priority  ind  right  upon  its  side,  has  two  good  reasons  for  being 
a.lmitted.    There  are  those,  on  the  other  hand,  who  go  even  farthe 
thnn  we   and  sav  that  inflammation  includes  not  only  the  changes  at 
tiie  site  of  injury,  but  every  other  change  in  the  body  at  large  that 


T^rm 


rilK  LOCAL  REACrinS   TO  IRRITATIOX—IXFLAMMATION     1 H) 

iu(()ini)aiiit's  this;  this  is  apt  to  confusf  the  leanuT,  and  the  distant 
cliaiigfs  will  he  dea't  with  by  us  in  coiisiderinp  firnfntl  rrartion  to  injuri) 
tiud  infection;  so  that  we  restrict  the  term  inflammation  to  the  local 
ciiaiiKes  in  any  tissue  that  reacts. 

The  process  of  inflammation,  occurrinf;  in  the  invertebrate  animals, 
we  shall  touch  upon  merely  to  illustrate  two  fundamental  principles, 
two  modes  of  defence  against  injury,  and  at  the  same  time  two  mcnles 
of  repair  of  the  damage  inflicted,  for  thus  early  in  our  consideration  of 
tiie  subject,  it  is  necessary  to  show  that  the  processes — inflammation 
and  repair — are  inseparable.  These  two  principles  are  (1)  that  sooner 
or  later  a  proliferation  of  cells  of  the  part  concerned  occurs,  and  (2) 
that  there  is  a  determination  of  wandering  cells  to  the  injured  area. 


Klci.  H4 


Kio.  .3i 


1/ 


meA 


of  (»n('  nf   the   simplest   metazoan  forma 


'  -\^tropt<  ten)  to  show  ret.,  ectoderm;  fitil.,  endo- 
il'Tjii;  tn(s.,  wandering  mesodermal  eelU  which  at 
/'/.  Iitive  attached  themselves  to  a  foreign  Ijody  and 
tnriiicd  a  Plasmodium  around  it. 


The  Plasmodium  of  fused  meaodermal  cells 
seen  in  the  previous  figure,  higher  magnifica- 
tion; nucl,  nuclei  of  individual  cells.  (After 
MetchnikoCr.) 


If  we  take  the  simplest  form  of  coelenterate,  we  find  a  differentia- 
tion into  ectoderm,  endoderm,  and  mesoderm,  as  in  Fig.  '44.  The 
111!  soderm  cells  are  formed  from  the  other  layers,  and  represent  what 
will  become,  in  higher  ft)rms,  the  supportive  structures  of  the  bo<ly; 
it  will  be  noted  that  in  this  simple  form  they  are  either  relatively  ^a;cfZ 
i>T  friT,  some  being  joined  loosely  by  cell  processes,  others  wandering. 

I I  an  irritant  body  be  introduced  into  this  cavity  the  cells  travel  toward 
I!  and  stick  to  it;  its  very  presence  irritates  to  reproduction  cells  in 
'  iitact  with  which  it  lies,  and  thus  new  cells  are  born;  these  cells,  new 
■Mill  old,  surround  it  and  if  it  be  digestible,  they  digest  it;  if  not,  they 
1'  nee  it  off  and  render  it  as  harmless  by  this  isolation  as  they  can. 

III  re  are  both  principles  illustrated,  positive  chemiotaxis,  or  attraction, 
a'lil  cell  proliferation.  This  must  be  kept  in  mind  later  on  when  we  find 
'lit  the  wandering   cells,    mesnh!a.stic    in   origin,  .are  the  cells  that 


120  TIIK  MORBID  AND  REACTIVE  PROCESSES 

exhibit  chen.iotaxis  an.l  rally  to  the  site  of  injury,  whereas  the  fixed 
cells  of  the  bodv  tend  to  proliferate  and  regenerate.  .      ,    „    , 

As  we  advance  farther  up  the  /.oiiloK'ical  scale  to  those  animals  that 
have  an  open  vascular  system,  hut  no  proper  vessels,  we  hnd  another 
fundamen  al  princii)le  illustrated;  if  the  ectoderm  be  punctured,  the 
Ivmph  which  bathes  the  cells  of  the  body  coagulates  and  temporanly 
sVals  the  hole;  this  is  to  be  remembered  when  we  hnd  m  our  studies 
on  the  human  body  that  a  scatlol.l  of  fibrin  is  construt-te.1  throuphout 
the  injured  area.  As  we  advan.e  once  more  to  the  higher  animals, 
which  have  a  closed  vascular  ..ystem,  we  hnd  that  these  same  simple 
features  persist,  and  that  the  vessels  serve  to  convey  more  readily 
and  more  rapidlv  lymph  ami  wandering  cells  to  the  injured  part,  there 
to  carrv  out  their  functions- the  same  functions  that  we  find  their 
counterparts  performing  in  the  lowly  organized  ccelenterate. 

Fig,  30 


FoTtifu  hrnlv  giiint  cells  in  tliyrmd  vesicle,  to  show  similar  plaamodium  formations  sur.ounding 
foreign  body,  .'.r  its  equivalent,  in  .nan:  a.  remnant  of  mass  of  colloid  in  centre  of  vesicle;  6  g.ant 
cells  attacking  the  colloid;  c,  giant  cells  that  have  air  fdy  dissolved  colloul.  (From  case  of  chrome 
interstitial  thyroiditis,  Ilr.  Rhea.) 

The  detail  of  the  inflammator\-  process  must  be  dealt  with  farther 
on  with  more  particularity.  _ 

The  Causes  of  Inflammation.— 1 .  Bacterial.  Bacteria  are  most  tre- 
quentlv  the  exciting  cause  of  inflammation,  whether  by  their  direct 
cctionin  originating  the  process,  or  as  an  adjuvant  to  trauma,  as  in 
infection  after  a  wound,  or  as  in  secondary  infection  after  a  burn  or 
after  the  action  of  some  corrosive.  It  becomes  at  once  evident  that 
this  admits  a  very  large  number  of  bacteria  to  our  consideration;  there 


-TT' 


■«««■ 


» 


THE  LOCAL  REACTION  TO  IRRITATION— INFLAMMATION     121 

arc  the  pathogenic  organisms,  such  as  the  Bacillus  tvphosu'^  or  the 
Strcplococcus  pyogenes,  which  can  inaufiurate  inflammation;  there  are 
the  saprophytic  organisms  which  cannot  grow  in  the  body  normally, 
l)iit  wliicli  can  multiply  in  surface  discharges  or  on  mucous  membranes, 
mid  there  liberate  toxins  which  can  be  absorbed  and  cause  inflamma- 
tion; the  non-pathogenic  forms  are  able  to  do  nothing  of  this  kind  and 
tor  our  |)urposes  are  negligible. 

If  we  are  dealing  with  a  microbe  capable  of  setting  up  or  of  assisting 
to  set  up  the  process  of  inflammation,  it  is  by  no  means  certain  that 
tlie  inflammation  will  be  of  a  definite,  fixed  degree  of  severity;  every 
case  of  bacterial  inflammation  is  a  problem  in  which  it  is  necessary 
to  gauge  the  virulence  of  the  organism  and  the  resistance  of  the  patient; 
and  we  shall  see  that  varying  grades  of  intensity  and  rapidity  of  the 
l)rocess  are  thus  set  up. 

Bacteria  may  attack  the  body  directly,  being  carried  to  and  im- 
|)lanted  upon  it  from  the  outside,  or  from  the  mucous  surfaces  of 
tlic  throat  or  intestine,  just  as  the  ^sopian  viper  bit  the  country- 
man who  warmed  it  in  his  bosom.  Another  form  of  infection  is  of 
Rreat  clinical  importance.  It  some  i-nes  happens  that  an  operation 
wound,  made  with  the  most  careful  asepsis,  becomes  infected;  it  is 
l»)ssibie  that  there  may  have  been  some  fault  in  technical  work,  and 
till'  bacteria  may  thus  have  come  from  the  outside;  but  it  may  also 
liappen,  and  does  happen,  that  the  patient  supplied  the  infection  him- 
M  If,  and  that  bacteria  were  carried  from  some  of  his  storehouses,  the 
tiiroat  or  the  intestine,  by  way  of  the  blood  to  the  wound,  because 
tilt  wound  is  at  the  moment  the  part  of  least  resistance  in  the  body. 
This  implies  that  there  are  bacteria  in  the  blood;  such  we  believe  actually 
to  be  the  case.  It  is  true  that  blood  cultures  of  the  healthy  yield  no 
LTowth;  nevertheless,  there  are  indications  that  from  time  to  time 
liacteria  are  being  picked  up  from  the  upper  air  passages  and  from  the 
iiit(  stine,  and  that  under  ordinary  conditions  these  are  rapidly  destroyed 
li>  the  agency  of  the  blood  and  endothelium;  but  if  living  bacteria  be 

arricd  to  a  part  where  the  resistance  is  low,  as  a  wound,  then  in  place 
'  I  undergoing  destruction  they  are  able  to  make  a  foothold  and  multiply. 
One  very  important  function  of  the  liver  is  to  kill  off  the  bacteria  carried 

I 'III  the  intestine  in  the  portal  blood;  for  the  portal  blood  picks  up 

:    t  only  food  particles  from  the  bowel  but  also  organisms,  whose 

iviiiains  can  be  found  in  the  liver  at  any  moment.    It  is  true  that  the 

I    '  ttria  which  escape  into  the  blood  are  quickly  destroyed  by  several 

!i(ics,  and  the  internal  organs  are  potentially,  if  not  actually,  sterile. 

i:   I''  these   "chance"   organisms   which    cause   the  latent   infections 

■>    i  the  terminal  infections,  which  last  so  often  supervene  upon  some 

' !    ■nic  disease;  an  example  of  this  is  that  a  case  dying  slowly  of  heart 

i^c  is  generally  found  to  harbor  some  inflammatory  process  such 

•iieumonia,  which  arises  not  by  infection  due  to  highly  pathogenic 

i<il)es  brought  in  from  without,  but  from  bacteri"    oft.n  of  low 

'i  lice,  which  hitherto  have  been  impotent  to  r'  -    *iothold 


7U    .  .■s*-. 


:jr,-,::u^' 


1..2  rilK   MOIiliin  AM)   HKMTIVK  PROCESSES 

a  small  .    iiintr  <     u.um  .  .    nreseiK't'  ot 

Tlu'  procfss  ..f  iuHaiumatu.n  is  nuisi-.l  not  ^^^  tlu  """  P'^^;' 

tin-  process  cf  itiHammation  in  a  simple  torm.  viz.,  tht  series 
,  ?  «•<.  «,,  1  tissues  that  uiulerK'..  inHammaticn  solely  trom  this 

:i:at.:;'lSLn\ .;  il^ul"  J^sponse  to  irntation,  even  in  the  same 

"'tis  ;;:::tion  of  tlu.  .liferent  resisting  powers  of  di^erent  kl^  of 
CH-Us  will  repay  closer  consideration.    We  are  able  roughly  to  diMde 


a  HA  DBS  OF  INFLAMMATION 


123 


the  (flls  of  the  b(Mly  into  the  ijarenchymatoiis  an<l  the  supporting; 
the  former  are  specialized  to  do  special  work,  and  are  exemplified  by 
the  nerve  cells,  liver  cells,  kidney  cells,  and  so  on;  the  latter  perform 
more  lowly  fnnctions,  and  are  concerned  in  no  skilled  work,  as  it  were; 
such  tissues  are  the  fibrous  connective  tissue,  subcutaneous,  or  as  the 
framework  of  organs,  tendons,  ligaments,  fascia",  and  so  on.  The  body 
may  be  likened  to  a  community  of  which  the  parenchymatous  cells 
are  the  professional  und  the  skilled  members,  and  the  supportive  struc- 
tures the  "laboring  classes."  In  a  general  way,  the  professional  classes 
are  more  highly  trained,  less  robust,  do  not  reproduce  readily,  and  if 
one  die,  his  place  may  be  fi"  d  only  by  a  person  trained  like  himself. 
So  it  is  with  the  parenchymatous  cell  in  each  of  these  particulars. 
On  the  other  hand,  the  laborer  does  relatively  simple  work,  reproduces 
readily,  is  unmoved  by  the  ordinary  turmoils  of  public  questions,  and 
if  lie  die,  his  work  is  done  by  a  neighbor  who  needs  no  special  training 
to  take  his  place.  So  it  is  with  the  supportive  cell,  in  all  these  particulars. 
If  now  we  have  a  poison  of  a  certain  intensity  acting  upon  a  paren- 
cliymatous  cell  and  a  fibrous  connective-tissue  cell  ride  by  side,  the 
former  is  more  damaged  than  the  latter,  and  what  is  sufl^cient  to  kill 
the  former  may  only  irritate  the  latter  to  proliferation. 

At  this  point  we  shall  consider  the  efVects  of  irritation  on  the  individual 
icll  of  whatever  kind.  Let  us  suppose  a  toxin  of  very  slight  severity, 
it  will  irritate  the  cell,  stimulate  it  to  greater  activity:  if  a  secreting 
( til.  to  secrete;  if  a  supportive  cell,  to  reproduction.  If  now  the  poison 
111-  a  stronger  one,  it  has  the  power  of  proflucing  change  in  the  cyto- 
plasm of  the  cell: — first,  the  change  we  are  accustomed  to  call  cloudy 
swelling  or  cloudy  degeneration;  the  cytoj)lasm  swells,  the  outline  of  the 
1(11  may  become  less  distinct,  the  plasm  may  appear  more  opaque; 
if  the  degenerative  process  goes  farther  the  cell  becomes  granular, 
like  ground  glass,  and  it  may  show  fatty,  hyaline,  or  other  degenera- 
tion (although  we  do  not  know  exactly  what  circumstances  determine 
t'lic  form  of  deger ..'ration  and  what  another),  and  finally  may  die. 
This  gradual  adv  nee  toward  death  we  have  designated  as  a  bio- 
iiK  rescent  process:  if  the  toxin  be  yet  stronger  the  cell  may  be  instantly 
UlliMJ.  We  can  thus  picture  to  ourselves  a  toxin  killing  at  once  the 
' '  il>  nearest,  causing  the  bio-necrescent  process  with  subsequent  death 
ill  .hose  a  little  farther  away,  the  same  process  with  recovery  in  those 
.  '  I  farther  away,  and  cloudy  swelling  in  those  still  more  remote,  while 
tl  "M'  farthest  removed,  yet  within  the  sphere  of  influence  of  the  toxin, 
i:v  merely  irritated  to  activity  of  function,  phagocytosis,  chemiotaxis, 
•1  rcijpoduction.     In   every   composite   picture  of   inflammation,  the 

i  lent  must  keep  in  mind  that  although  we  may  lay  stress  upon 

'  '  r  more  macroscopic  features,  yet  in  each  field  there  may  be  cells 
i:   all  stages  of  "sickness." 

Inflammation  in  a  Vascular  Area. — Let  us  consider  what  hrippens 
■  I'!',  a  tissue  as  the  ordinary  lax  -subcutaneous  tissue,  plentifully 
-  i'iilied  with  bloofl  vessels.    In  this,  let  us  suppose  that  the  irritant — 


^■i'  n       :i£i.^' ' 


'-^. 


:^^^^^ 


124 


Tin:  MontiiD  asd  rk active  PRncE^^Es 


sav  a  clump  of  hactoriii  is  imiltiplviiin:  tin-  toxins  arc  hciiiK  K«vcn 
off  in  all  directions.  The  first  step  which  is  ohservc.1  on  the  jmrt  of 
the  tissues  is  that  tlie  capillaries  <lilate,  and  the  stream,  thtainh  larger, 
becomes  slowi-r;  at  the  same  time  the  leukocytes  heum  to  drop  out 
of  the  hlocxl  current  an.l  laj;  alonj,'  the  v.  alls  of  the  capillary,  where 
presently  a  whole  row  of  them  is  seen.  These  hcfjin  to  progress  throuRli 
the  capiilarv  wall,  hv  a  HowinR  movement  of  the  protoplasm-  diapedesu 
-an.l  soon"  some  are  to  be  seen  outsi.le  the  vessel.  Serum  has  also 
been  exuding  at  the  same  time,  so  that  the  coimectivc-t issue  cells  come 
t.)  lie  well  apart;  manv  of  these  last  are  noted  to  be  in  a  swollen  state. 


i-Ki.  :)7 


Inflan,rd.,...«.nt..r>-..f  tr..g:  «.  n,nrKin«tinn  „f  l,.»kooyt..s  in  tl,e  .lil«..-.l  capiUuri..,;  h,  mi,irati.,., 
of  leukocytes;  r,  ornHp.'  of  red  corpus.les; ,/,  a.L-».i.uhi.i(.u  of  Icukorj  t™  ouUl.le  the  oap.llanox.  (After 
KibU-rt.) 

What  is  now  going  on  is  a  struggle  between  bacteria  and  serum  aided 
by  leukocvtes  and  sometimes  by  tissue  cells,  for  if  the  last  are  not 
too  severelv  injured  they  will  proliferate,  urged  thereto  by  the  irrita- 
tion of  the  toxin.  The  leukocytes  and  the  newborn  cells  of  the  part 
are  activelv  "  phagocyting"  the  bacteria,  and  many  microbes  are  thus 
destroyed.'  In  the  meantime  the  blood  in  the  capillaries  is  circulating, 
and  the  Ivmph  outside  of  them  is  also,  in  its  own  slow  way,  circu- 
lating, so  -Ihat  it  will  readily  appear  that  there  is  great  activity  in  sucli 
an  area;  the  area  in  question  is  now  a  mass  of  leukocytes,  of  cells  of  the 
part,  old  and  newborn,  soggy  by  reason  of  the  excess  of  lymph  which 
has  exuded  from  the  capillaries.  Up  to  the  present  moment,  then, 
we  have  a  preliminary  dilatation  of  vessels,  margination  of  leukocytes, 


■3jr-r- 


''Wl 


»«»»"B^  ~  *-«  r.^xs 


WrvvT? 


IXFLAMMATinX  OF  VASCULAR  AKKAS 


125 


I'ui.  38 


(liapedt'sis  of  the  sium-,  t-xudatioii  of  soriim,  and  phagcM-ytosis.     At 
this  stane  the  part  iiiHamed  will  show  tiie  chtssic  sijjns  of'  inflamma- 
tion, dolor,  rubor,  calor,  tumor;  <iolor,  or  |,,iin,  hecaiise  of  the  irritation 
ol  the  nerve  endinjjs,  rul)r)r.  or  re(hle^■s,  liecause  of  the  excess  of  blood 
whwh  is  i)resent  by  n-ason  of  the  dilated  vessels,  ealor,  or  heat,  because 
ot  the  nicreased  flnshiiiK  .,f  the  part  by  the  warm  blowl,  and  tumor 
or  swelhnjj.  because  the  tissue  is  bulkier  than  it  was  by  reason  of  the 
excess  fluid,  by  the  h'ukocytes  newly  brought  in,  by  the  tissue  cells 
newly  born,  not  to  mention  the  >;reater  bulk  of  blood  in  the  vessels, 
'i'his  mass  of  leukocytes  and  other  cells  is  now  on  the  i)oint  of  hecominK 
:iii  abscess;  if,  however,  the  resist- 
jince  of   the    body  be  successful, 
tile  bacteria  become  eaten  up  by 
the  cells,  or  attacked  by  the  lysiiis 
iif  the  serimi,  and  the  leukocytes, 
which  have  not  died,  wander  away 
ii;rain  or  are  carried  by  the  lympli, 
the  excess  lymph  itself  disappears, 
the  bodies  of  the  cells  which  have 
•  lic.l  are   disintegrated,   and   the 
pieces    "scavenged"     or    cleared 
iiwiiy  by  their  living  fellows,  and 
the  tissue  becomes  as  it  was  at 
first,   with  the  exception   of  the 
proliferated  cells  of  the  part,  which 
rciiiaiii.    These  fibroblasts  in  time 
Ixfuiiie  true  functioning  connee- 
ti\c-tissue    cells,    and    the    total 
n  Milt  of  the  inflammation  is  that 
th(  re  is  a  fibrosis,  an  increase  of 
thcM'  fibres  at  the  spot  where  the 
iiiliiiinination  existed.     This  con- 
>tUiitcs  the  process  of   repair  or 
iili-iirption   in   an  inflamed   area. 
1 1 .  liowever,  the  fight  is  not  won 
l'\   the  cells  but  by  the  bacteria, 
H  i.>  .onsider  what  happens.    We  revert  to  the  stage  at  which  we  have 


1,  iulhi-aion  of  leukocytes  to  tlio  walls  of  a 
Ciipillary  in  an  inflatnr.l  area;  2.  nioili.  of  miara- 
tion  of  a  polynurloar  leukocyte  seen  under  higher 
magnification.     (Lavdonnky.) 


,1  - 
ill 

(ill 

iiiL 

th; 
(i\ 

iin> 
ri',' 
111,1 
ill- 


■  ■ "■  ••"'-  oiff^t  til,  niiifii  we  nave 

uy  mass  o   leukocytes,  new  cells  of  the  part,  bacteria  and  serum, 

Mt,     the  mflammatory  mass."    As  the  bacteria  multiplv  and  give 

More  toxms,  more  and  more  leukocytes  die  by  reason  of  bacteria 

ted  or  of  toxin  absorbed;  especially  those  leukocvtes  and  cells 

Mrc  most  in  the  cc-ntre  of  the  mass  are  apt  to  die,"  because  their 

"I  and  food  supply  ,s  cut  off  by  the  dense  crowd  surrounding  them 

'heir  excretion  is  not  carried  away  freely  from  them  for  the  same 

■):  when  they  die    ^ye  And  that  the  centre  of  the  inflammatorv 

•"■comes  a  mass  of  dead  and  living  leukocytes  and  bacteria  float- 

^erum  -m  other  words,  pus,  and  the  whole  area  with  its  containe<l 


ii-,   iri^^t^" 


IL'O  TIIK  MOUnil)  AS'D  RKMTIVB  I'ROfESSKfi 

pus  forms  nil  abfcess.  Tlit-  tissuoH  yet  alive  hcrdfrinn  on  this  liquefiiMJ 
(•nitre  art-  in  a  «ase  that  is  litth-  »M'tt«-r.  aii<i  snpiairation  spreads,  and 
the  tissues  horih-riiiK  the  abscess,  as  it  were,  melt  into  it  until  the  abscess 
.•itiier  breaks  to  the  ontsich-,  is  opened  by  incision,  or  stops  by  virtue  of 
the  tissue  resistance.  .     ,    ,  i 

Hefore  we  consider  how  siicli  a  h-sioii  is  repaired,  let  us  glance  a 
moment  at  the  varying  grades  of  (rllnlar  implication  we  meet.  At 
the  edge  of  the  tissue  bordering  on  the  pus,  the  cells,  leuk(K-ytes  and 
tissue  cells  alike,  are  in  a  bad  wa\  ;  many  are  severely  hit  by  the  toxin 
and  are  dviiig;  as  we  i)rofrress  outward  where  the  toxin  is  U'ss  strong 
we  find  cells  that  are  severely  but  not  fatally  "sick";  farther  out, 
cells  that  are  perhaps  in  the  state  of  cloudy  or  granular  swelling,  onl.v 
slightly  "sick";  whereas  on  the  outside  is  a  ring  of  cells  only  exeiteil. 
called  "in  by  chemiotaxis,  irritated,  and  these  form  a  kind  of  leukocytic 
ring  like  jiolicemen  surrounding  the  area  of  disturbance  to  see  that 
none  of  the  otlVnders- the  bacteria -escape;  and,  once  the  disturb- 
ance has  subsided,  to  carry  off  the  maimed  or  dead.  In  every  "  itiflam- 
matory  wh.w"  nr  ran  find  rrlln  showinu  ecery  firatle  of  dnnuKjr,  and  gener- 
ally speaking,  the  connective-tissue  cell  will  sutler  less  than  any  of  its 
fellows,  parenchymatous  cells  or  leukocytes. 

The  Repair  of  an  Abscess.  -If  the  pus  be  evacuated,  it  remains  for 
the  tissues  to  fill  in  the  gap;  this  is  (h»ne  by  the  cells  of  the  part;  the 
connective-tissue  cells,   irritated   to  rei)roduction,   bring  forth  fibro- 
blasts large,  soft,  vegetative  cells,  which  heap  up.  taking  their  nourish- 
ment from  the  Ivmph  and  from  the  slips  of  new  capillaries  that  begin 
to  grow  between'  them.    These  cells  in  the  mass  'urin  granulation  tissue 
(in  the  words  of  the  laity  "proml  flesh").     If  the  abscess  be  drained, 
there  is  no  great  amount  of  .severe  toxin  in  contact  with  them,  and  they 
rapidlv  jiroliferate  and  Hll  nn  the  cavity;  if  the  pus  still  remain  in  con- 
tact with  them,  this  acts  as  a  permanent  irritant  and  they  are  prone 
to  be  killed  bv  its  toxins;  if  the  wound  be  much  wiished,  the  washing 
is  apt  to  float  them  away;  in  cither  case  the  process  of  filling  up  is 
retarded.    If.  however,  they  get  a  chance,  the  space  is  quickly  filled  up, 
even  overfilled  by  these  big.  soft,  young  cells;  in  the  course  of  time  these 
cells  become  more  fusiform,  throw  out  processes  which  anastomose 
with  one  another  (see  Fig.  4:^),  and  later  give  off  or  control  the  forma- 
tion of  fine  fibrils  which  appear  in  the  intercellular  spaces,  gradua  y 
grow  smaller,  firmer,  more  like  adult  fibrous  connective  tissue,  till  finally 
each  fibroblast  has  become  a  connective-tissue  cell,  tightly  bound  to  its 
fellows,  strong,  and  smaller  in  bulk  than  when  it  was  younger  and  softer. 
This  is  the  scar;  it  occupies  less  space  th  ..   did  the  granulation  tissue 
it  represents,  and  therefore  occurs  the  contraction  which  characterms 
the  scar;  it  is  dense,  an.l  this  accounts  for  its  hardness  and  unyielding 
character;  it  is  also  relatively  bloodless,  through  pressure  upon  the 
r)r  'viouslv  ahuiid:int  capillaries.     If  the  pus  has  not  been  evacuated, 
it  remains  as  a  kind  of  foreign  body;  its  serum  drains  away,  and  from 
being  liciuid  it  becomes  of  the  consistence  of  butter,  then  of  the  con- 


_/-  ".■WK-.vr.-Ts^yw.  -rsmtmat^  s'v  "Si-'-i  i'^^^s  ««»» 


^5ng.-p— ■  H( JKW  I-.-TI"^ 


FACTUns  1\  THE  INFLAMMATORY  I'KOCESS  Il>7 

sistcncc  of  clufsf.  atHi  finally,  dry  or  inspissate«l.  .Meatitime  tlu- 
surn.iindiMK  tissue  has  b«'»  fonniriK  granulation  f  ssuo  ahoi.t  it.  and 
this  fjranulation  tissue  Iwcomes  iti  time  sear  tissue,  and  the  scar  in 
of  hluiK  uf)  tho  nap  where  the  original  l<.ss  of  tissue  ocurml.  sur- 
n.,n.ds  the  dne<l-up  p„s.  as  with  a  wall.  The  remains  of  the  pus  in 
t.ine  requently  InH-ome  permeate.!  hy  calcareous  material  deposite<l 
rom  tiie  IymF)h  so  that  such  an  abscess  may  he  finalb  representwl 
by  a  mass  (,f  calcification.  surn)unded  hy  a  wall  of  fibrosis 

1  he  various  changes  noted  in  an  inflame.1  area  call  for  a  more  i)recise 
.lcs<ription  than  we  hav.-  Riven,  and  some  particulars  mav  be  outline.! 

Circulatory  Change*.  With  the  a.lvent  of  the  irritation,  the  vessi'ls 
momentarily  contract,  an.l  then  .lilate;  and  yet  at  the  same  time  the 
Imv  ('f  bl(),M!  IS  not  (pucker,  but  rather  slower,  and  the  serum  of  the 

' "'  ""^^"'K  *•"*  ••»  the  part  is  more  abundant  and  contains  a  hidier 

IMTcentage  of  solids  than  is  ordinarily  f<..ind.    The  chinRe  in  caliber 
..t  the  vessels  IS  m.t  <!ue  to  the  influence  of  the  central  nervous  svstem 
l.ut  IS  probably  brouRht  about  by  some  local  effect  on  the  vessel' walls 
ihcmargmation  of  the  leukocytes  is  not  so  much  an  active  qualitv  of 
the  leukocytes  themselves  as  cause.!  by  a  change  in  the  end.ithelium 
nf  the  capi  lanes,  by  which  it  gains  a,i  agglutinative  qualitv. 

1  he  eyu.lati..n  of  serum  is  not  merely  an  accompaniment  of  the 
(  ilatation  .)f  the  vessels  but  is  an  in.li.-ation  of  some  .hange  in  the  en.l.,- 
tlKlium;  the  exude.!  s,Tun.  i-,  more  ba.t."ri.,lytic  than  normal  bImHl 
MTum.  although  m.)st  ..»  this  quality  is  gaine.1  at  the  site  .)f  inflam- 
niation,  w-here  it  pi.ks  up  protclyti.-.  antit..xic.  an.l  ba.tericidal  sul)- 
>tances,  the  pr.Klu.-ts  .lirect  an.l  in,'r.<>  of  cell  diss..luti..n.  especiallv 
111  l.'iik.>cytes.  '^ 

In  all  the  prece.ling  paragraphs  we  have  sai.l  nothing  about  fibrin 
t-ni.ation.  winch  is  so  obvious  an  accompaniment  .)f  inflammation  on 
;|  Mpons  or  a  mucus  surface.  Vet  even  in  deep  tissues  it  mav  exist. 
Hi.'  s<Tun.  supplies  fibrnu.gen.  the  leukocytes  fibrin  ferment,  the  b.Hlv 
ii.ls  the  necessary  calcium  in  the  mciuim,  and  fibrin  is  deposite.1  in 
.(■  tissue,  where  or.lmarily  its  existence  is  but  a  short  one.  because 
"I  the  presence  ot  prf)te..lyti.-  ferments  which,  rea.lilv  i)roduce.l  bv  the 
p,  "Keiiic  organisms,  quicklv  dissolve  it. 

The  EndotheUum  of  the  Bloodvessels.-  We  have  in.iicated  that  the 

■I  nthehal  cells  lining  the  bl...,,ivessels  an.l  onstituting  the  walls  of 

.|^  .apillaries  are  n.,t  '•  tiles"  lai.l  in,  as  in  a  m.,saic.  but  are  active 

H  L^  ]oinc,l  t..  .)ne  aiu.ther.     Flu-y  can  expan.l  and  contract,  they  can 

P'  .  rn  to  s.,me  extent  the  quality  of  f|„i,|  passing  between  and  through 

I;  .)::  they  have  even  been  seen  t..   ,end  out  pseudopmlia  and  seize 

■■    >.T  a  in  contact  with  them,  an.l  they  are  a.tive  phagocvtes.     It  is 

""le,  th..ugh  not  provtMl,  that  the  large  mononuclear  cells  of  the 

'I'    .1  arc  the  progeny  .>f  these  en.lothelial  cells.    Wht     the  capillarv  is 

•'    r.cted.  the  spaces  between  them  are  small,  but  when  the  vessel  is 

I  ';"<  ,  they  are  large,  and  it  is  through  these  spaces  that  diapedesis 

"1   '  nkocytes  occurs;  it  may  wcur  that  red  blood  cells  are  pusW-d  out 


S,i':Et:X.'r£'^^::/ar' '^f  i.i.i»^  is -.Ua.  part 

"V^;XSt,.  t.  the.  .n....u.al  .^^^^ 

H,,„,  ,,-„,ph  SP..;-  -;:  ,,  »';,^''t':V  trn  fn^-n  tl.nn  ale  lar^e. 
repnHiuc-t...n;  ami  *»^*',;'' ,',„f' '^...""^.tivelv  phaK.KVtic.  Tl.esr  <-ells 
aci.lophili<-.  liyahne  cells  that  «  /'J  J^'^  »  J",,  .".j  ^,,,.  ,«„»■  ..nler 
we  find  lyiMK  mM  the  t.ssue  ••^'l  •  «"  '^'^\,;",  L-e.  The  fil.n.ns 
as  the  l«^P^^O•uU^e  eel  Is  Kuen  c,  b  a  ;-;;'';  „f  ,,„.,,.,,ive 
coiineetive-tissue  eel    wh.eh  ^^^''  »' *  V'  '  j  \, ,"  ..   ,„„i  the  .ells  that 

'PI. ..■•..(<>»>    ii   matters  not  wlietner  ii"    i""^>".'      • 

ir         {.;  1.S  strean.  the  lymph  stream,  the   t^ue  spaees  .. 

""tT-'b  Jd'i;ttr'"Th.  lH.k,«-.vW  ar..  c»ll.,l  to  tW  part  tlmt  is  inflam^l 
the  7^^'''^';"'\^*'™ ;^V   e^^^  ooneentration;  it  implies.  t..o.  .  ccn- 

'"''Phrtnk.,evtes  that  take  part  are  the  polynuelear  (properly  poly- 
proteolN  tie,  and  bacurRuiai     .         ,,-i        ^v  the  endothelial 


PLATE   III 


',' 


^# 


J    . 


Jt    * 


«s; 


^ 


*# 

* 


^' 


'^' 


n- 


w 


ilci  inc)  Colls  in  ihe  Peritdn^i 


il   Fluid  of  a  Rabbit  Twemv- 


I'un    Hoiiis  aller^  In.jet  udh  of  B.  coli  into  the  Peritoneal 


Cavity.     (Beatlie.) 


-K'.w    til.'    i-.'hitiv 


e   |ir«  ip<nMi(in    i 


if    polynuclt 


nuinoiiililenr    (Il  i>~toi|enoli«   ur    liyiiline)    1 


iitul    et)**iii(jphi  le    lei-ik( 


|ihiu|<>i'vi(i-sl-..  |><>lyniii>lenr».  eosii 


■  hil 


eiikofiytes.      There 


'Hi  nm<  U'jir- 


iloiui    with    hiiilllmy    |>h!i.|o<-y' 


e*<.   red    <_'t>rpvi«cle**  hy 
hy  the   polyniif'leHi'?*. 


FACTORS  IX   Tin:  IXFLAMMATOHY  PROCESS 


129 


w.iikly  phagocytic,  it  yet  lias  lu'cii  seen  to  wander  through  the  vessel 
Willi,  and  to  ingest  particles,  Init  not  tiie  bacteria  of  suppuration.  It 
may  he  that  tlie  lymphocyte  can  give  rise  to  the  plasma  cell,  of  which 
r.inre  anon.  The  important  point  to  not.  is  that  while  in  a  verv  acute 
inflammation,  tiie  result  of  virulent  toxin,  they  are  rare,  in  a  low  grade 
mllamination,  caused  hy  a  less  active  toxin,  they  are  common.  So  much 
i>  tins  the  fact,  that  in  a  serous-sac  inflammation  we  are  in  the  habit  of 
<<>nntmg  the  cells  in  the  exudate,  and  of  concluding  that  a  large  per- 
I'litage  of  Ixmphocytcs  speaks  for  an  inflammation  of  second-grade 
intensity  like  tuberculosis,  and  not  for  one  of  first-grade  virulence  like 
that  set  up  by  the  pyogenic  organisms.     The  lymphocyte  originates 

Fig.  39 


•M 


iij 
ji  /. 

nf 
-nil 
Tl:. 
tll, 

til,. 

Ik,', 

IK,   ■ 


IM^.m.l,■.r  l,.uk,,..yt.'S  infil.rutinK  Ih.-  riroular  mm,-\v  \:,y,r  of  an  aruflv  inflan,,.,!  apmmlix- 
«.  a.  rn.l.,th..lml  ,;Mx;  b.  h.  pnljimcloar  IvukcMytrs-  r,  nuHrus  of  nm»..|<.  .-oil. 

uiyiitcst  abundance  from  the  lymph  nodes;  it  has,  however,  to  be 
"  ni  iniiid  that  in  the  sheaths  of  most  veins  there  is  normallv  present 
"I '  "t  lymphocytes,  and  that  those  which  accumul  -  in  an  area 
"-laiiimation  are  not  necessarily  all  derived  from  j  blood,  but 
"  It  least  are  the  result  of  proliferation  of  these  loca.  Ivmphocvtes 
eosmophiles  we  cannot  yet  rank  in  their  proper  place;  thev  have 

■iiic  |)ower  of  migration  as  the  ordinary  leukocytes,  less"  power 
"  -Lr(»'\  tosis,  and  appear  early  in  some  acute  inflaiiimaticms.    Like 

"I.Muiclears  they  originate  mainly  in  the  bone  marrow  and  they 

•   .I"  part  111  the  formation  of  new  tissue.    We  may  sav  here  that 

"  ith  multiple  nuclei  or  a  partite  nucleus  does  enter"  into  tissue 


130 


THE  MORBID  AND  REACTIVE  PROCESSES 


l.uilding;  these  eells,  as  we  state.l  before,  are  marked  for  an  early  death, 
and  are  already  on  the  downward  road. 


Fio.  40 


Aiuic  l.Miipha.lonitis,  showing  a  lymph  »';;;'" ,<'°f '*'"""; 
down,  others  (i)  acting  as 


t.K  (ri)  large  endothelial  cells,  some  breaking 


phagocytes.    To  the  left  are  numerous  lymphocytes  (6)  for  comparison. 

Vw.  42 


ri<i.  41 


r- 1 


'    « 


■■^* LI. 


%•  ■    0, 


Fron.  a  typhoid  lyn.ph  nmle  to  show  I  he  swollen  endo- 
thelial .ells  or  macrophages  (a,  a)  acting  as  phagocytes  f, 
diflcrcnl  stages  in  development  of  san.c;  h.  the  same  uialer- 
going  disinligralion. 


Splenic  sinuses  from  B  case  ol 
typhoid  fever,  to  show  phagocytosis 
by  swollen  endothelial  sinus  oils 
la,  o).  These  contain  red  blo.Ki 
corpuscles,  in  various  grades  of  decol- 
oration and  disintegration;  6, 
■nmller  endothelial  cell;  e.  sinus  eel. 
undergoing  disintegration. 


_ 


-^rr-ser^T^^ 


PLATE  IV 


KIG 


@ 


* 


iA 


®    ©    r« 


.$• 


Wandering  Cells  from  tlie  Peritoneal  Fkii<l  ofn  Rabbit  Thirty- 
six  Hours  altei'  I  ntr'a|ierituneal  In.jeinion  of  B.  coli. 
(Beaitie.) 

7..  -hiiw  liii-,|t.   |iliiu|o<ytii-  niDJXimii-lear  cells   innesliiu|   | «)!  y  iiiic-l<-!u-  leuUo- 
<ytf«.   red   forpu^cles.  ami    liacteria. 

KIG     2 


>*> 


>»a^ 


*     1 


•.^-^ 


o 


•<^l 


■^. 


^^ 


-CJ- 


# 


1 


«? 


'iHui    Cells   (Mononurlenr    Hyaline    Histogenous)    (rom 
'"■  Perit.>neal    Fluid   Forty-eight   Hoins  after'  Intra- 
I'eritoneal    Injection  of   B.  coli.     (Benttie.) 

''•'^^    r'iia,|...  vi..~i-<  an. I   ,  1 . ,  |,.-.i ,,  ,i  i  ,>l   ]  .oly  nu<-lea  r  l.-iiU.  ..yie^  iiiid 
ilii|i'->ii  vo   vaiMiole-..     I  Laler  MlHue.) 


FACTORS  IN  THE  ISFLA^fMATORY  PROCESS 


131 


The  Fixed  Tissues. — These  play  a  very  important  part  lu  inflaniination, 
(Itsi)ite  the  fact  that  their  eells  are  h'ss  j)r«)niineiit  than  the  leiikoeytes, 
if  the  irritant  be  one  of  sli^'ht  dejrree,  proliferation  of  the  stroma  cells 
ai)i)ears  from  the  first;  if  of  high  degree,  the  stroma  eells  at  the  centre 
(if  activity  may  be  killed,  but  those  in  the  surrounding  areas  are  excited 
to  phagocytosis  and  to  proliferation,  and  the  degree  of  toxin  that  is 

Fio    43 


M 


*  iranuiulion  tiswuc  Been  from  the  ficeper  toward  the  upper  surface:    /,  spin<ilo  cells  (fibroblasts), 
li    -I    :ibunilant  in  deeper   portions,  where  they  also  are  becoming  shrunken;   (j/,  lymphocytes;  y, 

C!i-.lliirics.     (I(ihl)ert.) 

ii  Ic  to  kill  a  leukocyte  is  probably  not  able  to  kill  a  stroma  cell,  or  a 
fii  nius  connective-tissue  cell  as  we  have  called  it  previously.  In  the 
i!i  :i  of  inflpmmation  and  appearing  there  as  a  result  of  the  pr  u'css, 
^*  find  three  sorts  of  cell,  which  we  will  describe  one  by  one.  (1) 
''  hyaline-mononuclear  cell,  which  is  like  the  cell  appearing  in  the 
'i  i.  whu-h,  too,  we  have  stated  above  to  origiii^te,  in  all  probability, 
i;     '  tiie  tissues;  (2)  the  fibroblasts  proper,  oval,  becoming  spindle- 


,:52  TIIK   MOIWID  AND  RKAVTiyt:  I'HOrKSSES 

sl.lpo.1.  ..ri.inatin,  m-.n  tl,o  fil.mus  ......nective-tissue  c.lls.  and  CO  the 

so-callo.  plasma  cells.  ..sntriallv  nuii.onms  on 

The  Mononuclear  Hyaline  Cells-  1  ll^^'"/^^;;  ;  ^,,j,,.  f„,m  the 
•„,HanH..l  sc-rous  surfacrs,  an.l  an-  '  jf  ,^'^^^™  ,<  vi.>K  ether  areas 
,,  ,  ,  Hu.n  of  tl.os.-rH.u..,  so  ^;-;-,.:;^,(,,,^,,,,  ,,,  this 
of  the  ho.ly  <-«"'^'<"'-  tl  •  t  ^IpL  ;  ■  '    .ti,,,,s  of  phajioeytosis  we  have 

The  FibroblMts.     Ilu»,.  ""„'""':,,      *^„H.,.ti,ms  with  the  c-lls 
cells  snch  as  their  parents  were. 


F  '1.  44 


^ 


c 
.'''  — 


f^    "■■■   ^  0^  ^^  ^     ' 


liascmcnt  iiieiiibraiip. 

*f  rX'h";;:.;  MuxI,,,.,.,  a  v^y  c,,„.bU.  .bBen,r.  M.  .  o„n- 


PLATE  V 


deh. 


mlHiion  Tissue.    The  Upper-  is  toward  the  Outer  Surfnoe. 
(Maximow.) 


'  .    <!i|ulliii-y     eililotheliuin  ;     i,< 


cap.,    encloilieliii 


of    newly     forminy 


ill;nv;    fhl.    fi  I  )roblast-, ;    /,,   i>i)ly  mulear    leukocytes:    x,  the    polylilasu 


nliiui    "  polyhUist." 


I  i-^)  ,      dth.t    tlehi'l 


of 
t\'     leiikoirylea ;     dtQ,,    a 


m^^^^- 


TJT 


FACTORS  IS   THE  ISFLAMMATOIiY  l>l{OrESS 


133 


siderable  following  in  siip|)ort  of  tlu-  vii-w  that  the  plasma  cell  is  hut 
one  phase  in  the  lif»'  history  of  what  lie  terms  the  "polyblast,"  a  cell 
that  is,  which  may  originate  either  from  lymplioeytes  (»r  connective- 
tissue  cells,  which  may  develoj)  into  fibroblasts  and  so  into  eoimective 
tissue,  or  into  clasmatocytes,  large  cells  with  pr«)nouiice(l  processes, 
which  are  constantly  she<l,  into  "mast  cells"  of  the  tissues,  or  cells 
filled  with  large  basophile  granules  or  into  cells  .)f  the  Hbove-<lescribed 
plasma-cell  type.    The  matter  is  still  un<ler  debate. 


Fin.  45 


Pulyblut  ■ 


J'ihntltliiyt 


DeKener- 
ilti^    poly- 
bla.st 


Pcilyblast 


Fibroblast 


Developing  connective  tiiwuc.     (Maximow.) 


Inflammation  of  a  Mucous  Surface.— In  putting  together  the  details 
which  driractcrize  an  inflammation  of  a  nuicous  surface  we  have  to 
consider  not  only  the  surface  itself,  but  also  the  tissues  that  underlie 
it  for  a  short  distance,  because  these  also  are  attacked  by  the  irritant. 
In  them  the  process  is  that  which  we  have  just  described.     In  the 
milder  conditions  what  we  observe  is  a  swelling  and  active  prolifera- 
tion of  the  epithelial  cells  of  the  mucous  surface,  and  the  prtMluction 
both  by  these  cells  and  by  the  small  mucous  glands  of  the  part  of  abun- 
dant mucin.    There  is  thus  produced  a  surface  discharge  of  serous  fluid 
mixed  with  abundant  mucin,  loosened  columnar  cells,  some  few  leuko- 
I  ytes,  and  where  these  are  more  abundant,  there  may  be  present  in 
this  discharge  scattered   threads  of  fibrin.     This  is  what  is  termed 
catarrhal  inflammation.     Where  the  irritation  is  more  extreme,  there 
tlic  columnar  epithelium  of  the  part  may  be  completely  cast  off,  and 
\sitli  this  the  character  of  the  exudate  is  changed  from  a  mucinoun  to 
;i  more  serous  one  with  abundant  leukocytes,  and  with  the  formation 
iiiui  deposit  of  fibrin  this  forms  a  moist  layer  of  interlaced  fibrils  that 
'  iitaiigle  in  their  midst  leukocytes,  often  bacteria,  while  the  interstices 
i(  full  of  serum.    Add  to  this,  there  are  generally  superficial  cells  that, 
•  t  tucked  by  the  toxin,  damaged  or  killed,  have  become  separated  and 


r  > 
I'i* 


Hi 
H 


134  T//K  .WO««/i>  -lA'O  RHACriVK  PROCESSES 

y    ;..  tl...  exudate   for  such  is  the  name  appHed  to  the  miiterial. 
now  he  in  the  exuaate,  lor        n  „.,•,'      if  the  e\u<  ate  con- 

i„  most  striki„K  t™"ir,.        Ins.      '^  i^'^^.  "„.  ''^."^  .iv.lv  numcmus 

„,  inimeroih.  tlu  t  .'I". n™'  '»  >'.  '     ,    j  ,.||       „|,p„.oial.l<;  quantity, 

""l*  '.:'•<'';"«  iS'        n 'an"!  «1»  pu,.'  Jbttaopim....;  it  « 
serofibni  ^us,  ii  tiitrt  is  mui.ii  s,,.f„pp  slouchs  away,  necrotic 

ine.nbrane  appears,  membranous    .1  ^  ^„  ™  „S  K  st  or  «n^    sueh 

at  closely,  all  are  at  ooiimu  i  ..nr^nrentlv  ditterent  forms  of 

come  about  that  we  speak  «^ -\'J^«';  JJf  ^  f  ^t  eclueated  to  dis- 
inflammation;   the  truth  is  that  tht  tissues  "«  "«       j    ,     ^j     ^^^^ 

taxis,  in  and  around  the  '"^ured  a  ea     Ii  se  ere    ,r^^^  ^^^^^^^ 

s?l;  r j:ntff::'»™"=7';llvf  ^^^^^  j^«---: 

organisms,  successive- stages  may  be  made  out.    As  in  the  course 


IXFLAMMATIOX  /.V   \()\-\ASCULAIi  AREAS 


13.-) 


few  hours  the  inoculated  niicrohes  begiu  to  proliferate,  it  can  he  ohser'  'd 
tliat  the  surroundinjt  corneal  corpuscles  become  distinctly  swollen  and 
sliow  evidences  of  defeneration.  With  this  there  is  a  s:'"iilar  accumula- 
tion of  leukocytes  out  (»f  the  surrouiKling  I\ni|)h  spaces  toward  the 
focus  of  irritation,  in  a  few  hours  more,  the  circular  vessels  at  the 
perii)hery  of  the  cornea  hecouje  dilated,  and  with  this  there  sets  in 
a  migration  of  leukocytes  from  the  vein.  While  this  is  prr)ceeding  the 
corneal  corpuscles  in  the  immediate  urea  of  bacterial  growth  break 
down,  and  the  proliferating  bacteria  infiltrate  over  a  larger  area  until 
such  time  as  the  accunndation  of  leukocytes  from  all  sides  forms  a 
harrier  arresting  their  further  escape.  From  this  poirit  on,  the  inflamma- 
tion is  similar  to  that  seen  in  a  vascular  area  with  this  notable  exception, 
tliat  obviously  the  chemiotactic  influence  which  led  to  the  migration 
of  the  leukocytes,  exerts  itself  also  upon  the  wall  of  the  circular  vein, 
so  that  now  buds  or  processes  pass  inward  toward  the  affected  area 
imd  then  become  develoi)ed  into  true  capillaries,  which  may  persist 
weeks  and  months  after  the  acute  itifiamtuDtion  has  subsided. 

In  the  heart  valves  a  process  similar  to  that  in  the  cornea  is  seen; 
tlic  area  here  is  exposed  to  the  double  insult  of  a  toxic  or  bacterial 
irritation,  and  seventy-two  blows  per  mimite,  so  that  ulceration  is 
likely  to  ensue.  Oti  this  is  laid  down  fibriti  and  in  it  leukocytes,  for  in 
iiiidition  interaction  ensues  between  the  ulcerated  surface  and  the  blood 
uliich  bathes  it.  There  are  thus  proiluced  fibrinous  vegetations,  and  the 
lilirin,  in  the  course  of  repair,  is  replaced  by  fibrous  tissue.  In  those 
iMses  in  which  the  irritant  is  not  very  powt-rful,  it  seems  that  there  is 
;i  i)roliferatiou  of  the  connective  tissue  of  the  valve,  without  anything 
(l>e,  so  that  a  heap  of  new  fibrosis  arises  from  the  edge  of  the  valve, 
mid  constitutes  a  vegetation  of  a  fibrous  kind  from  the  very  outset.' 

Chronic  Inflammation. — From  the  wa\  we  iiave  insisted  upon  the 
uniformity  of  the  process  of  inflammation  so  far,  it  may  be  inferred 
that  we  are  not  in  favor  of  building  up  a  barrier  between  so-called 
;iiiite  and  so-called  chronic  inflammations;  and  such  is  the  case. 
Arc  we  to  call  an  inflammation  acute  if  it  reaches  its  height  in  one, 
t.\i>,  three,  or  four  days,  and  chronic  if  it  takes  five  or  ten  or  fifteen? 
W I  do  so,  but  it  will  be  seen  that  the  distinction  is  arbitrary.  Or,  if  we 
ar(  ill  doubt,  as  clinicians,  whether  an  inflammation  is  acute  or  chronic, 
;iri  we  to  compromise  and  call  it  subacute?  As  clinicians,  yes.  But 
tinin  the  pathological  standfwint,  it  is  unnecessary,  because  in  all  we 
-  .  the  same  mode  of  reaction,  a,  b,  c,  d,  e.f,  as  we  have  said  above. 
Ii  the  irritant  be  of  low  degree  of  strength,  there  will  be  less  killing  of 
'!  Hie  and  more  proliferation,  if  of  high  degree,  more  killing  and  less 
1  iliferation,  more  serum,  it  may  be,  and  less  diapedesis,  but  in  everj' 
'  I'  the  procedure  a,  b,  c,  d,  e,  /,  runs  through  all,  as  the  theme  runs  in 
ii  I'itce  of  music  all  but  hidden  under  variations. 


\  fre(,  .ent  mistake  of  the  student,  is  to  confuse  ^5roiM  &ndfihrinoti8.    The  term 
^nous  can  be  employed  only  to  designate  ^.he  result  of  depo.sition  of  fibrin.   ' 


13(i 


TIIK  MORliW  AS  I)  REACTIVE  PROCESSE.^ 


TIh'  sHlu-i.t  ftatnn-  ..f  an  ii.fla.ni.iati.m  cans,.!  I,y  an  inttnsf  irritant 
is  .xiKlatinn;  .lia,M-.l.-sis  .K.urs  l.ut  littl.-.  hrcaus.;  .lu.inH.taxis  is  iu-km- 

can  .HTiir  only  at  tiu-  outskirts,  whore  tlu-  toxin  is  nuII  .1.  ntnl;  at  tl, 
mitro.  cvn,  ilu-  stron«.-st  <rlls  are  kille.l.  Tlu-  striking-  feature  of  an 
inflammation  .aiise.!  I.y  a  p'.itle  irritant  (muI.  an  one  as  we  ..ften 
.•linicalh  eail  chronic)  is  proliferation.  l.e<ause  there  is  a  ininimuiii  of 
killiiiL'  of  «t11s.  of  irritation  such  as  .alls  f.irtli  ahnn.lant  exmiutmii 
„„.!  ,li„pe.lesis.     Between  th.se  tw..  extremes  o.rur  many  Rra.les. 

i}nt  'lu-re  remains  a  fre<|Uently  ma.le  error  to  e..rre«t.      1(m.  .)fttn 
we  sneak  ..f  a.lhesions  hetween  the  lay.rs  ..f  the  p.-riear.liuin  as  «hron.r 
neri.'anlitis  in.^t,n<l  nf  rorrfcth,  vnUiu.j  it  the  rr^ults  of  a  past  pencarditi,^. 
I'leiiral  a.lhesions.  nine  times  ...it  ..f  ten.  .1..  lu.t  in.li«-ate  a  chronic 
pleuritis.  that  is.  a  .lis.ase  n .-t  a.tive.  hut  in.luate  merely  the  repair  ..f  a 
disease  a.tive  loi.K'  a«o  an.l  n..w  heale.l.  as  far  as  may  I.e.    \et  a.lhes.on 
miirht  he  slowlv  set  up  hy  a  mil.'  pn.eess  of  irritati..n.  an.l  such  w..ul.l 
he  ...rrectlv  enough  ealle.l  .hroni.'  plenritis.  hut  this  oeeurs  rareb   in 
e,..nparis..ii  to  the  rapi.lly  pr...luee.l  plenritis.     Another  similar  mis- 
take  is  t..  speak  of  a  heart  as  the  victim  ..t  chrome  fihr.n.l  myo.ar.lit  s 
when  wc  sh..ul.l  say  a  heart  with  fihn.ses  wlmh  have  rcsulte.l  from  ol.l 
mvocanlitis.     The  termin..l..Ky  matters  comparatively  little,  it  it  t)e 
un.lerst.HHl  that  the  process  is  essentially  a  uniform  «»>e;  the  student 
shoul.l  take  heart  from  tin-  c..nsi.lerati..ii  of  the  simplicity  ..  the  mflam- 
niatorv  pr..cess;  if  he  im.lerstan.l  tlu-  invariahle  reactmn  ,.t  the  tissues 
he  will  see  it  in  every  case  of  the  .liscase.  even  it  it  he  f..r  the  moment 
c.)n(rale.l  hv  tin-  pre.l.)minan<e  ..f  s..me  one  feature. 

The  Vascularization  of  New-formed  Connective  Tisstie.-In  ad.litioi 
t.,  the  pr<.liferation  ..f  the  .rlls  ..f  the  part,  that  is  the  form.ti.m  .> 
Hhn.hlasts  an.l,  it  may  he,  ..f  plasma  cells,  an.l  lar«o  hyaline  cells,  it 
nnist  he  re.alle.l  that  the  vessels  ,)lay  an  a.tive  part  m  the  later  repara- 
tive stag's  of  an  inHainiiiati..n  an.l  this  particularly  where  there  has 
heen  active  .l.-stru<ti..ii  of  tissue.     In  all  su.li  cases  what  is  termed 
irrantilation  tissue  is  f..rme.l.    This  name  is  taken  from  the  appearance 
of  a  healing  superHcial  w..un.l.  th.e  Kranulati.)n  heing  .lue  to  the  presence 
of  closely  set  new  capillary  l.K.ps.     On  such  an  inflaine.1  surface  at 
first  is  inerelv  a  lavcr  ..f  leuk..cytes  with,  it  may  he,  a  few  fihrohlasts 
an.l  large  hvalinc  cells,  hut  imme.liately  heneath  these  it  can  be  made 
out  that  the  .lilate.1  superficial  capillaries  show  tmy  hu.ls  or  thicken- 
injr.  '/  their  eiulothelium  .lirected  toward  the  surface    and  presently 
thes.      hu.ls"  elongate,   sen.ling  proces.ses  outward,  w-hich  processes 
from  a.ljacent  capillaries  join,  hecome  more  prominent  become  thicker 
are  holl..wed  bv  the  bloo.l  stream  an.l  rapidly  assume  all  the  characters 
of  a  new  capillary.     Fr..m  these  new  loops  other  bops  are  formed 
a.lvancing  int..  the  area  which  is  t..  be  fille.l  up,  until  this  area  is  filled 
with  a  framework  of  new  vessels,  which  are  supporte.l  an.   sepai  ated  by 
the  tissue  cells  which  have  c.ntinue.l  to  be  simultaneously  proliferatci 
i„  the  meshes  of  this  framework.    This  constitutes  yrunulatum  tissue, 


ORA  \ ULA  TIOS  7  ISSUE 


vx, 


or.  on  a  surfuw.  what  tho  layiimi.  tmns  "prou.l  fl.sh."  Onlv  thost-who 
hav,-  watchni  a  larn(>  (l.-rp  woiiimI  ImmiI  in  a  li.Nilthv,  Krowin"if  .liil.l  can 
a|.|.r.ri«t,.  tlu-  trntl.  ..f  tho  a.lHR.-.  "Tlioro  i.  in  tlu-  tissues  an  almost 
.n>u|MTal,le  t.-n.  nuy  to  heal."  Th.-  j.hysician  niav  suc-coe,!  in  ov.t- 
•onnnK  this  ten.h-nc-y  if  he  he  me.l.ll,some  and  foolish.  If  there  he  a 
Krannhitnig  surface.  ren.emlK.r  that  antiseptics  will  succeetl  in  killing 


Vm.  40 


I  nr  nw.on  of  new  ve»«.N  ,„  granulation  u,,ue:     1,  from  a  Z».^\ex\  cl,a„,b<.r  (form«l  of  two  rovor- 

-li>-)  l-ft  ,n  tho  pentoneal  oavity  of  a  ral.l.it  fo,   forl.v-<.iKht  .ia.v»;  portion  of  fi,-!.!  lx,uml..d  t,v  ,„o 

>   forn„-,l  new  ,-ap,ll«r,e8-  l^two-n  ,h..n,  can  1«  aeen  the  »oli,l  l„„ls  ami  pro<-..>«,.,  of  dev.-lopim, 

•  Ti^K  :'."'"■  "•  .k"!"  r  "'"""  P"""^""""  «"  "h"*-  formative  ell,,  or  fibroblast.,  ,„  .lirect  eonncT- 
'    -1  with  the  endothelial  processes.     (Ziigler.) 

ti.se  tender,  newborn  cells,  that  a  stream  of  water  mav  wash  them  awas 
'"'\  nature  may  have  to  do  her  work  over  again  on  vour  account  If 
.v-'i  see  pus  on  the  surface  give  it  a  chance  to  drain  awav  if  possible, 
"i:t  remember  that  granulation  tissue  presents  a  ver>-  strong  barrier  to 
•y  ^Tpuon,  aii.i  die  pus  may  do  less  harm  than  the  clum.sv  sponge 
It  removes  it.  The  pus  from  a  granulating  wound  was  called  bv  our 
I'     fathers,  who  understood  the  drainage  of  wounds  as  well  as  we  do 


i 


138  THE  MORBID  ASD  REAVTIVF.   PROCESSES 

L-   i.f   "fxuberant  jjriui illation 

;;rS^t;tC:VCU"n  W  trL..trate  ...;  .—ions 
-^:  SJ^irOr^Sas,--  The  n^^^^^^  ^^JZ 

,,,JeHects  .rou.ht  by  '^^^I't  "^1^  sB-  lepra-,  H.  mallei, 
forms  of  plant  htc,  ^"^■'\  "r.,*^  jl;.  ,  Ini.hun,  ami  even  the  larv^ 
actinonnees,  ''l'>^t"'"^■^■^■^  J "i;",4e  tissues  build  up  a  Nvall  around 
and  eggs  of  certam  paras,  c  V^^'^^  „evv-fornuHl  tissue  we  call  the 
the  irritant,  so  to  speak,  and  ^"J  "''»;^;;\,^  ..,,,  ,,,,,y  he.    It  is  evident 

li:;Sr^of1;::^Set  ^r  of  tl.  tubers  or 

ShJJSS  by  the  bacilU  ancUlieir  pr^ua.  ^^^  .^  .^  ^,,^^^     , 

A  word  as  to  the  f.^^f^^^^^,  J^  «rthe  irritant  of  tuberculosis 
ago  it  was  realized  that  the  /^  't  m  aforetime  called  a  tumor, 
Xs  a  "lump,"  the  t"^-^^  ,*^  ^^.^^  was  foun.l  to  be  of  fibrous 
and  was  classed  among  tun  or.,  ^^^  ^»  J '^  ,,^,i  .^,  .'tumor  of  granu- 
Lue,  i.  c,  of  *^'--">«t";"Jf;;>,^'irt"^nation-o»,a  which  we 
lation  tissue,"  or  ^^'^f;^''^^'''^^  'l  r.  NVIhm.  it  was  discovere.l 
have  nnule  to  sign.ty  the  i.lea  '^ J  »  f  ^,,5,  j,ranuh>ma,  it  was 
that   the  «.  tuberculosis  ^^a.  t'l^     '.V'^*;  ^,,^.  „„,,  the  class 

aesignated  an  •*i>;''*?-^l-/^":;";Xh.s  bee  discovered;  and  now  we 
has  grown,  as  each  infective  agent  '^'Y,  "'^^;  ,^.  „„  inHammatory  one, 
a?e  iible  to  state   that   the   proc  >>         P  ^^^  j.^„„,  the 

ind  that  the  grauuloma  ^^  ^^^^^  ^J^,  to  the  toxin  of  the 
proliferation  of  the  c'  Is  ot  the  part  ^^^  ^^^^  .  i„Hamraa- 

organism  concerned.  In  /"•^•/^".^^'^^^Vt  ,„  of  the  granuloma,  although 
tory  area"  above  is  true  tor  ^^;  ;^'  ^  \  in  ot'the  B.  tuberculosis 
the  process  is  a  longer  one  >» /""  ,•/  ^^^^^..^^.^ate  exudation  of  serum 
causL  a  dilatation  of  the  ^^^^^  )  '^^ !  ^"proliferation  of  cells  of 
a  slight  diapedesis  o  ^^^'^^^o  :*»;;,;  ^  ,i,h\erm  we  mention  only 
the  part-the  ^r''V^'^     £^L^^^^  ^-^-"^  "r  the  proWerated 

to  reject;  they  should  be  ^•"""'  J  ''^^^^^^^^ 

cells  if  the  part;  while  the  -f  e  ^   -;;'-^    ,,,,„  ^api-Uy  into  pus  and 

serum  ami  badly  "^^^f  j,"^,  ."^  "th    granuloina  breaks  down  slowly 

an  abscess  is  tormed,  the  ctntri  o    ^"^  |^      j        j^^^j  ^  cascated  granu- 

,to  a  formless  mass  o  dry  necrosis    ^^  a Uon    a     ^^^^  .^^^  ^^^  ^^^  ^._^^,^ 

loma  is  the  r^ult.  J>''--»  ;;j;,^' ,  ]  ^^^^l'  ,  rallelism  betw.;cn  these 
a  subacute  inflammation.  '^•«7;;'  '""^tion  is  this:  if  tubercle  bacilli 
ap  nts  and  those  causing  acute  "  "'  »  "  f  ^^^^Jcute  iuttan.mation  not  to 
are  in  sufficient  numbers  they  J;''';^^^  ^^^^^f^  ,,acteria.  The  same 
he  distinguished  ^;o";  '^^^^  ^  U lenders  bacillus,  while  in  man 
,„^,  been  shown  to  be  tnu  ^^]\J^  commonly  a  central  area  ^^lth 
the  mulule  o  «^'t>!»'"^>f  ^  v  cs  n  Set.  contains  true  pus,  while 
ahun.lant  polynndear  »f  »^"'  J:^'  ^i-ue  '■*'"^- 
around  this  is  a  /one  of  proliteratid  ti.,.uc 


INFECTIVE  GRANULOMAS 


139 


Tlie  tubercle,  the  gumma,  or  the  nodule,  thus,  is  a  mass  of  new-formed 
connective-tissue  cells,  and  these  cells  are  the  essential  part  of  the 
tubercle;  the  trained  microscopist  must  become  used  to  recognize  the 
granuloma  by  this;  the  giant  cell,  of  which  more  anon,  is  unessential; 
the  caseation  is  an  unessential,  save  that  if  sufficient  time  be  given  it 
is  an  almost  inevitable  sequel,  at  least  in  cases  of  tuberculosis;  the 
ring  of  leukocytes  external  to  the  mass  is  also  unessential,  although 
tiie  more  acute  the  process  the  more  likely  it  is  to  be  present;  the 
inolif crated  tissue  forming  the  "lump,"  the  tubercle,  the  gumma,  the 
nodule  is  the  essential,  and  the  only  essential.  And  in  most  cases  of 
these  maladies  the  unit  is  tht  grainiloma,  and  a  cavitated  lung  is 
merely  the  final  result  of  necrosis,  secondary  infection  and  what  not 
(in  an  aggregation  of  small  granulomas. 


1  [III  re  If  from  a  ease  of  tuberculosis  of   medium  severity  of    the  lung:  a,  central  caseation;  h,  a 
liiant  itll.  c,  endothelial  cells;  d,  conaective-tisaue  lone  infiltrated  with  lymphocytes. 

Giant  Cells. — Although  not  a  necessary  character  of  a  tubercle,  the 

-iaiit  cell  is  very  frequently  found  therein;  this  is  characterized  by  a 

I  iru't'  body,  made  up  of  ill-staining,  acidophilic,  necrotic  material,  with 

crescent,  a  ring,  or  a  group  of  ordinarily  stained  nuclei;  this  is  some- 

•  iiics  clearly  the  result  of  fusion  of  a  grouj)  of  cells  to  form  a  plasmodium 

round  a  small  mass  of  necrotic  material  or  of  bacilli— in  other  cases 

:  11  re  are  indications  of  actual  nuclear  multiplication  with  incomplete 

inplasniic  division.    The  giant  cell  is  often  found  close  to  the  necrotic 

irt  of  the  tubercle,  and  in  this  edge,  or  in  the  giant  cells  themselves, 

<■  bacilli  are  to  be  most  readily  found.     Interspersed,  too,  with  the 

■  '■  liferated  cells  of  the  i)art  are  lymphocytes  and  rarely  leukocytes— 

r  former  are  the  "small,  round  cells"  of  inflammation— and  on  the 

i-ide  is  a  more  or  less  pronounced  ring  of  lymphocytes  which  have 

■  n  attracted  to  the  area  of  inflammation  by  chemiotaxis. 


%W^1Si?'.. 


THE  MORBID  ASD  REACTIVE  PROCESSES 

,  .a.  be  useful  to  recall  t>K.-»;^^P-— Jj^^  J^jf  ^iJl  t 
„ --leans  limited  to  tul,era.l..>.s:_«ocnuUr^.^^^^  ,,Umyc..sis. 

oiher  infective  granulomas,  •";:'''•';;  t.Vce     is  seen  fiUe.!  with  the 
nnrl  Lrkuders.     A  somewhat  sinular  tM)t 


Here 
bv  no  means 


and  glanders 


Fig.  48 


•f 


Giant 


- « ..".  -^  r  ^;"=r  ;^i^irzrr;,;-  ;.:;r  ^  — ' 


type;  b,  b.  the  same  in  proccs 


Flo.  49 


-i 


A„wn  u,  FiBs.  :«i  a;;  ^;;1    ;  r  1';  "  !»..;..,  and  »,„«re„.ly 

■l;;;;i  r.  r  r^  1,"'  ii.  "'lis  -'  •".«"■"  -  >=■""-•""'  -'-■""• 


CUROSir  IS  FLA  .W.U.t  T/O.V 


141 


Yet  other  mnltimiclfiitt'd  Ki«>it  cells  are  not  infrequent  in  other  forms 
of  sarcoma,  while  in  certain  cases  of  Ilodnkin's  disease  we  may  encounter 
relatively  hu>;e  cells  which  are  truly  giant  cells,  hut  have  only  (me  or 
two  nuclei. 

Diffuse  Inflammation.-  Sometimes  the  organisms  of  the  inft'ctive 
firanulomas  do  not  set  up  the  localized  nodule,  hut  we  find  a  diffuse 
fihrosis  such  as  happens  in  the  pia  mater  in  syphilis;  nor  is  this  con- 
fined to  the  jiroup  of  orpinisms  which  cause  the  graimlomas,  for  a 
good  example  exists  in  cirrhosis  of  the  liver,  wliere  there  is  a  general 
increase  in  the  connective  tissue  of  the  part  without  there  being  &\y 
particular  localization.    It  may  be,  however,  that  this  diffuse  fibrosis 

Fio.  60 


'.9 


V 


'V^' 


/•' 


<^ 


y 


I 


3 


W 


e 


9 


^3 J  \%^\  o^ 


t 


S.I  lion  from  n  syphilitir  livrr  wlii.h  presonto.I  mimmnta  nlonK  with  n- '  nsivf  cirrlicsia      The  mv. 
I  Mi,.-.l  ronnoftivc  tisKuo  is  wen  .xKn.ling  Iwtwpcn  ami  rutting  off  i  '  of  liver  coIIb,  which  u  a 

-uli  aro  shrunkun  ami  iitrtipiiit'il. 

i    iiii  ai't«-r  result  of  the  existence  of  small  n  •  granulomas.    At 

Mines  it  appears  to  be  caused  rather  by  the  tox  the  organism  than 

I  \  the  organisms  themselves.    Such  a  fibrosis     a  cirrhosis— is  common 
•I  the  li\cr  in  syphilis,  as  well  as  in  cases  where  a  long-continued  expo- 
ire  of  the  liver  to  the  bacterial  and  other  toxins  of  the  alimentary 
•  iict  leads  to  the  fibrosis  which  is  known  as  "cirrhosis  of  the  Hyer.|| 
iitre  is  a  further  class  of  cases  which  we  term  "chronic  inflammation," 
liieli  arise  in  a  way   similar  to  this.     Such   are  chronic  nephritis, 
vroiditis,  anil  hepatitis,  all  of  which  we  recognize  as  caused  by  an 
itant,  yet  in  which  we  think  faulty  metabolism  and  imperfect  nutri- 
11  are  also  of  some  cH'ect.    It  is  supposed  that  under  the  influence  of 
turbed  or  excessive  activity  the  secretory  cells  become  degenerated 


W^ 


rr,    Avn  RF ACTIVE  PROCESSES 
142  THE  MORBID  ASD  REAL iivi^ 

.„„  „.,  *,. ..«;.» .--,*-'-^  *:i.r™r  Se*-  «5 

lower-class  supportive  cells.  j        er.th  has  the  proliferation  of 

Fibrosis  and  mflammatoon.-  S    ^J^^^      -^.^^^^^  ..^h  inflammation, 
connective  tissue  been  .^fj^^^,  X,vs  the  result  of  inflammation? 
that  the  question  arises,    I^fJX  formation  of  a  fibroma  or  a  ne^^ 
The  answer  is  in  the  negatiY  ,    ^    torm  ^^^^^.^^^^.  ,,j  fibromatosis 

growth  is,  of  course,  a  case  "  P"  "V  ]  ^  ^^^  the  readiness  with  which 
^.f  elephantiasis,  o  '"«;^''^'^";X; mcttn  to  the  exit  of  the  lymph  by 
fibrosis  occurs   f  there  be  a    ^^^^n^^^^^  ^^  ^lie  lymph  prevents  the 

its  ordinary  ^"'^"""•^^^  J^xh  s  o  t  e  eefls,  which  toxins,  remaimnp, 
free  <lrainage  away  of  the   oxmsot  the  c  ^^  ^^^^^  ^^^  ,nflamma- 

niav  ex.-ite  the  fibrosis;  t  us  ».'*^^"'"';.,,"the " absence  of  obstruction 
Si;  although    on  t^e  otlu.  ^  .^^^^^^^  ^,  „„,        ^  toxin, 

of  the  veins  there  ma>  ''^*[,;V"".^  result  of  stress,  to  be  presentlv 
and  the  process  imy  be  re^ard^l  as^  e  ^^^^^^^  ^  ^^^^^  .^  ^^  ^^^^^^ 
mentioned.  Final  y.therei  tfe^"  i.f  arteriosclerosis.  Here  we 
by  fibrosis  of  the  intima  of  ^^'^  ^^  f  j.^arily  f- r  site  of  change, 
find  two  forms:  >"  'I'J^'^'/^V irrU-ition,  but  the  ot(urs  are  a.lapme. 
an.l  this  we  may  attribute  to     "tation  ^^^^  „,generated; 

t.>  strengthen  the  -"'V f  .^  ^^^^.^  £ev  ic  infiltration  or  formation 
such  fibrosis  occurs  -'^,^«"*  '"^^tlv  ^plained  by  what  we  have  not 
of  new  vessels,  and  ma>  ^^^  P"/  J^^  ^^.tion,  namely,  stress.  It  cells 
previously  adduced  as  a  ^«;'  ^  «;|^'f  t/^eh,  or  even  are  intermittently 
are  put  upon  a  constant  ^^?;^^l,^,A,  proliferation  ensues, 
exposed  to  such  a_stress,  i*   h^J  »'t  ^^e^        ^^_^^  ^^^_^^  ^^^  ^^^^.  ^^  ,^  too 


;i;;.l  to  such  astress,  ^^  ^hey  be  we    no..n..j.,  .^^  .^^^^  .^  .    ,^, 

th'  distension  acting  as  a  sfm|dant^   1    r  ^^^^  inflammation. 

great  a  stretcli  of  the  ""^P"'^*';'"  \" 'X  1 1  Hcation  than  is  gen^-rally 
'  We  feel  that  tins  is  a  principle  of  ^s  u^^-ppc^.^^^^     ^^_.^.^   ^^^^^^ 

appreciated,   the   P"-f  P\^;  "«"^;  f ',  ^  is  able  to  cause  the  growth 
either  as  pressure  or  traction  "P^i    a  ce  ^^^^  ^^^^^  ^.^^^^  ^^ 

a„,l  proliferation  of  that  ^f  1-  ^" J^'^f^/   ho  force  acting  on  the  cell 
no  i.'erference  -th  vts     u^rmon    a^^^^^^^^^^  ^^^  ,        to    je 

is  not  excessive      ^'^/'f'f^  "'  .yhat  apphes  to  the  cell  mdniduall> 
opposite  condition  of  atrophy,     ^^f^  '^PJ       „f  experience,  it  is  found 
Sies  to  cells  in  t^- ^--f^''-i^^,fn  "bony'ri.lge  is  followed  by 
thit  the  constant  pu  hug  f^Ti^   i  creased  bony  growth, 
increase  in  the  size  ot  that  ridge,  *.    -, 
We  mav  thus  classify  the  fibroses: 

I.  Of  Inflammatohy  <'"><';^-      ,     f.,,^,,,,,  tissue  takes  the  place  of 

1.  Re,>larave„tfihro...  -^;;:^^  t""  scleroses"  of  the  nervous 
other  tissue  that  has  been  <  ^  '  ;,  ^^  i„,h,ae.l,  as  well  as  m  part 
svstem,  arising  from  glui;  "re  lure  to  nt  _ 

the  fibrosis  of  "nephritis    an.      '^^'P""  ;;  ^^^^,^,  ^f  the  graiuilomata. 

2.  rrolijeratire  Jibr<m.'<,  suet,  a^  •>  ,^  „ost-inflammatory 
and  those  around   foreign,   inert  bodies,        .   W   I 


SYSTEMIC  REACTION  TO  MICROBIC  INJURY— INFECTION     143 

fibroses  in  which  the  fibrous  tissue  continues  to  grow  even  after  the 
irritant  has  ceased  to  act,  as  in  keloid. 

■'}.  Post-fihrinous  fibroses,  which  replace  fibrin  in  a  thrombosed  blood 
vessel  or  on  a  serous  surface  (adhesions);  these  partake  of  the  nature 
of  both  the  above  groups.  They  are  replacement  fibroses  in  that  they 
replace  the  fibrin,  and  proliferative  in  that  they  occur  where  previously 
no  tissue  proper  existed. 

II.  Ok  N'on'-inflammatory  Origin. 

1.  Due  to  strain,  as  in  some  cases  of  fibrosis  of  the  inti:  of  the 
\essels. 

2.  Neoplastic,  e.  g.,  fibrous  tumors. 


THE  SYSTEMIC  REACTION  TO  MICROBIC  INJURY— INFECTION 

The  term  infection  is  used  in  different  senses  by  t\\".  pathologist  and 
tlie  hvgionist.  For  our  purposes,  infection  is  a  process;  it  consists  not 
ill  the  mere  presence  of  pathogenic  bacteria  in  the  mouth,  skin,  or 
intestine,  but  in  the  growth  of  those  bacteria  in  the  tissues,  i:>  the  diffu- 
Mon  of  their  products,  and  in  the  reaction  brought  about  in  the  body 
li\-  their  presence.  Infection  is  the  interaction  between  the  body  and  the 
iiiicrnonjanism  (jroimuj  in  it.  This  interaction  may  be  local,  and  the 
process  will,  in  that  case,  be  one  of  infective  inflammation  already  dis- 
nissed;  but  we  are  now  concerned  with  the  general  disturbances  which 
tullow  such  local  growth,  or  the  effects  of  a  widespread  proliferation 
of  the  microbes. 

The  hygienist,  on  the  other  hand,  considers  infection  as  the  mere 
linsence  of  the  harmful  microorganism;  thus  water,  air,  or  a  community 
may  be  infected;  he  distinguishes  (1)  sporadic  infections,  where  isolated 
'i-cs  occur;  (2)  endemic,'  where  a  notable  number  of  cases  of  a  given 
ili^ase  occurs  year  after  year  in  a  certain  area,  and  (3)  epidemic,  where 
i!h'  disease  suddenly  affects  a  large  number  of  people.  Similarly, 
(li -cases  of  animals  are  sporadic,  enzootic,-  and  epizootic. 

Causation. -We  have  already  considered  the  question  of  suscepti- 
li!iit\  to  infection;  it  may  be  repeated  that  there  are  various  ways 
1!  liich  susceptibility,  inherited  or  acquirwl,  may  show  itself,  so  that 
i! .  ()])])osition  to  the  bacteria  is  less  than  normal;  on  the  other  hand, 
li .  l)a(tcria  may  be  of  so  great  virulence  that  a  normal  power  of  opposi- 
li.  II  on  the  part  of  the  body  is  not  enough  to  protect  it.  Each  case  of 
■I  •  itioii  is,  therefore,  the  resultant  of  forces  which  are  always  varying; 
\'  I-,  tliere  may  be  great  susceptibility  and  virulent  microbes,  or  great 
~     rptibility  and  microbes  of  low  virulence,  or  great  i)ower  of  resistance 

I  •vi\  against  highly  virulent  microbes,  or  great  i)ower  of  resistance 
II.  iiist  lowly  virulent  microbes.    The  result  differs  in  every  case. 

The  Course  of  Infection. — To  indicate  the  course  of  an  infection  a 
i     ill  may  be  given  of  a  +ype  case  of  typiioid  fever.    The  patient  on 

II  CD  ilate  has  taken  into  lii    alimentary  canal  some  typhoid  bacilli. 


'  i'',"o'. ,  tho  pt-opk'. 


animal. 


mt'^^m;^^^^ 


1,,  THE  MOHBin  ASU  REACTIVE  PROCESSES 

,  •       •        t.wl  till  svmntoms  of  malaise  appear— 
F..r  a  few  .lays  n.>th,n,  -  ";f;"'  ,     ,,^^,7    ,onstipation.  pain    n  the 
lassitu.le,  slight  bu     P^'^j^;;^^  "  ^..     ^^   ,a  »  of  Letter,  an.l  ten  days.or 
hack,  an.l  so  ..n.     1  hese  Kro%   ^^  '^^'       '     i^.,,^  i,  ^o  weak  and  feverish 
so  after  the  ingestum  oi  ^1-  »»«  '^     »-^f  ,  ^J^  ^he  stage  of  incubation, 
that  he  takes  to  bed.     ^^'J'i^'^'  J!  symptoms  declare  themselves, 
during  which  proilromal  or  PrTre^of  rilehnite  febrile  state     lor 
the  stage  -»"t>n'"">^  ""^'^  ^^^'"^^  t„  .  ate  the  illness  from  the  hrst 
clinical  purposes,  it  is  ;"^*«J",:  Trrespon.l  with  a  recognizable 
prodromal  symptoms.  J't^^^SS  has  f^^^       S-neral  weakness, 

rise  of  temperature.     Ihc  patient  i  different  systems: 

'L\  various  sympt.>ms  or  sign  --j^bl  to^^ .,  ^,^  ,,i„  ,ead- 
(a)  in  the  nervous  system     he  e  JJ^>  .      ^^^^  tern,  a  rapid  pulse, 

ache,  and  chilly  ^^"^^^'""^  ,,^.^^  ^,"  J^'S ;  (c)  in  the  digestive  system, 
vasomotor  disturbances  such  as  ""^'^  nution  of  salivary  secretion, 
dryness  of  the  mouth,  by  -«f;- ^^tTod  1^^^ 

lo^s  of  appetite  or  a  P^  l^^^^^^^Jj^^-ith  foul  stools.  Day  by  day 
nain  const  pation,  or  at  times  diarrnceci«  ^^^  urinary 

?h  'fever  rises,  and  the  -y"^^'";i^ZZ:S^^f^^^^^^^  the  chlorides, 
secretion  is  evi.lenced  by  '''";"':;\':\llirthe  urates;  the  character- 
an.l  increase  in  "t^er  con  tituents   notaD  ^^^  ^^.^  ^^e 

istic  eruption  may  show  ^*7\."bW.l,  ami  later  tlu- serum  begms 
bacilU  can  be  found  mthej^rc...at.ngblo^^,^^^^         ^^^  ^^.^^j^^^^l  ^    ,11 

to  gain  the  property  of  being  a'''^"  ^J;^  ^1,;,  i^  the  stage  of  high, 
Thi'  is  the  stage  of  i^ryescence^  l^^  t .  ^^^  ^^^  ,,„ptoms  and 
continued  tever  or  lastlgluxn  ^  >  J  P  '^sten  ^^^^  ^^^^  j^  , 

increasing  weakness  and  loss  ot  tltsn.     i  .        ,        the  stage  of 

S^,  aLr  which  t)-/--  begnisj^>  iaUj.^^^^^^  ^.^,^  ,1 

defervescence,  which  m  turn  IS  t""^"^;;'  ^^^^^^  ,,hich  are  morbid  condi- 
return  to  health  and  strength.    ^o'^Pj^*!'"^^^       ,^,  „f  „ther  causation, 
ions,  either  ass.>ciate.l  with    he  oripn^l  ^au. .  ^^^^^ 

may  occur  durhui  ^f''^'^%'t.ZT^Zi\i  original  infection,  and 
niorbi.1  states  due  •'•^«^^t  >  ;; '"'^    .,  ^,  B.  tvphosus  or  inflammation 

:rr^a:is- ^^ '—  ^^- »--  -^^ '-  ^  '-''''' 

-S^^e^:nf'lncub«^ou.-Th^^^^ 

during  which  the  growth  ;f  .  ^  ^1  \  S;\  hich  the  diffusion  of  the 
,„,„,,  and  that  tune  ^f ''  ,  ^f  ^^.^  ^"Siently  great  to  g  ve  rise  to 
toxic  products  ..1  the  bactcr  a  "  y;;^^  ^..-e  accumulated  suffi- 
general  symptoms;  as  soon  '  ^XniS^lTmptoms.  It  is  to  be  remem- 
eiently  they  give  rise  to  ^^  P^~,t:  be^due  not  only  to  the  toxins 
bered  that  the  pnKlromal  ^>  ^^^^^r-j     ,5^,  (albumoses)  ma«lc  from 

%S;L\  the  rcAtunc  ot  the  orgamsm. 


SYSTEMIC  REACTION  TO  MICROBIC  INJURY— INFECTION     145 

Grades  of  Infection  It  min'it  appear  as  if  a  line  of  demarcation 
Wire  drawn  between  'ot; !  infections  and  general  infections,  and  yet 
tlie  differences  between  the  i/\o  are  diHerences  of  degree,  rather  than 
of  kind.  The  bacteria  w'liel  !,.  hoiee  are  of  hical  oeenrrence  may  be 
found  in  tiie  blood;  lately,  the  diphtheria  bacillus  which  was  supposed 
to  be  strictly  local  in  its  habitation  has  been  repeatetlly  found  in  the 
blood;  the  seat  of  election  of  the  pneuniococcus  is  the  lung,  but  it  also 
is  found  in  the  blood;  the  tyy)hoid  bacillus  works  its  local  effects  in  the 
bowel,  but  is  found  in  the  blood  stream.  It  may  be  considered  that 
every  organism  ca])able  of  local  proliferation  is  theoretically  capable 
of  being  found  in  the  blood  stream,  and  that  in  the  ca.se  of  organisms 
like  the  i)yococci  their  presence  or  absence  is  due  to  the  number  of  them 
that  escape  at  a  given  moment,  and  the  antagonistic  power  of  the 
blood  and  the  tissues.  Further,  with  regard  to  the  toxic  products  of 
bacteria,  we  are  accustomed  to  designate  their  i)resence  by  the  term 
int05dcation,  sapremic  intoxication,  or  sapremia.  This,  again,  is  a  rnatter 
of  degree  of  intensity  of  the  t()xic  products;  thus,  a  mild  local  infec- 
tion gives  off  a  certain  aniotnit  of  toxin,  and  this  is  carried  into  the 
blood  and  tissue  fluids,  but  is  so  diluted  that  we  see  no  general  bodily 
change  wrought  thereby;  we  neglect  such  a  mild  intoxication,  but  it  is 
nevertheless  present. 

Hefore  leaving  the  subject  of  terminology,  it  is  necessary  to  define 
the  terms  generally  used;  bacteria  mtdtiplying  locally,  and  giving  no 
\i>ible  signs  of  their  presence  in  the  blood,  ev  -n  if  there  be  indication 
of  toxemia,  constitute  a  case  of  localized  infection.  If  the  bacteria  not 
only  nuiltiply  locally,  but  are  also  evidently  in  the  blood,  and  are  getting 
toot  hold  in  the  tissues  (metastases)  the  case  becomes  one  of  bacteriemia. 
I'.M  li  of  the  metastases  now  becomes  a  centre  for  the  production  and 
.liiliision  of  more  toxin,  so  that  with  the  bacteriemia  the  toxemia 
iiilxances  equally.' 

I'or  clinical  purposes  we  are  in  the  habit  of  making  certain  rough 
ili-tiiictions,  dividing  infections  into:  (1)  fulminating;  (2)  acute;  (.'i) 
IM T-isting;  (4)  subinfection. 

!.  Fulminating  Infection. — This  type  of  infection  is  characterized 
I'  ~o  i;reat  a  Hooding  of  the  body  by  toxins,  and  presumably  by  the 
!!  !.  rtive  organisms,  that  tlie  resistance  of  the  tissues  is  notably  ineffect- 
lil  The  symptoms  are  those  of  great  intoxication  with  depression 
ni  ilie  luiK'tions;  the  heart  beat  becomes  rapid  and  feeble,  the  blood 
lH'   -lire  is  lowered,  the  respiration  is  shallow  and  rapid,  the  patient 


II  cmrcxporipiu'c  tlicrois  surli  painful  confusion  in  tho  niind.s  not  onlyot  student.s 
'f  nuMJical  men  in  RoniTiil  betwwn  tlie  terms  sopfirpinia,  sapremia,  pyemia, 

iikI  (ji'iioral  sepsis  or  blood  poisoning,  that  for  the  sake  of  clearness  we  prefer 
■  ii<e  llicni.  There  can  s\irely  be  nn  doubt  as  tn  what  is  meant  by  toxemia  and 
rninia;  lliev  explain  ihemselVes.     For  the  instruction  of  the  student,  we  woulil 

■  If,  as  popularly  employed,  localized  .septicemia  is  e(iuivalent  to  localized 
n,   itjeneralii!(!<l'>  septicemia  to  bacteriemia,  sapremia  to  toxemia.     Pyemia 

iii'.nv  uscfl  ;is  a  term  to  de^crilie  seplireiuia  with  metastatic  abscesses,  and 

!  ["lisoninn"  as  a  euphemism  for  any  or  all  of  the  above. 

10 


UO  THE  MORBID  ASD  RKMriVE  !'ROrESS,^ 

„«,.     If  tlH>  .Hseaso  is  .>m-  '■■;    "^^  ,,      "      i.Htv  .H-n'!^  <>"  "  ^  i"*''-"^ 
,„;,;,  is  present.     M.ch  an  o^  '7^"^,     ,,,,,;  „r  a  low  n-istanc..  ..r 
Uanism.  or  a  larp"  n.wnh.r  ot  '^^^"  ,'^; ,„  i,,  „.„K.n.luT...l  that 

,11  tlu.se  inlhu-ncrs  w..rkmj;  toR.tlur  »;.'",  ,„^.,ssary  virulenc-e. 
tlH-r..  are  ...>!>■  certain  .  'i-^^- .^  l^^^""  ^'u  tlu-  virulenc-e  of  the 
It  has  never  I.een  possible  '^^  _^^  ''^^  ^,,  .„.iuce  this  f«ln,inan<-e  ot 
tubercle  bacillus  to  so^reat  an  J^  "  *  ;\^  ^f  .^.  .„,a  epidemic  cerebro- 
.vn.pton.s.     (n-neral  bactenenua'  ^^^       f;*       ,.     So  rapidly  is  the 

spinlil  nuninptis  provule  ^^r^l-'fj^J^-'  ^  ^^-es  a  .le^eneration  of 
tI,xinpro.lu.e.l    an.'sol,.v^tM.t   ..t    hat^.^M^  _^^^^^  ^,^.^^.,,., 

the    ...uls  of  the  cap.llanes.   ^       »'•  .^^ 

„f  ten.pcratnre  bnt  even  a  ^;'';'';^'';i  ;;";;;i,^  ,,,.'e  ^vhich  is  evidenced 
.,f  the  bodv  are  not  stunnlated  to  ^''^ ^:}2v\yvnvvssvs  instea.l  ..f 

V  an  increase  of  heat  P-''-^;"'^  •;^:\n::'' !    u^^l  to  a  low  eW, 
,,-i„«  rendered  .nore  '-^j-    ''X- "-^  j    ,' form  of  infection  whch  has 
2.  Acute  Infection.-  1  his  .>  th,  '-"i '  ■'  j  ;„,!  „f  incubation, 

,„...„  aescribed.  .;here  m  a  -^  ^l^'^n  -^^  d^-----  '''''''  f^'^''""' 
,f  tVrve..ence.  ot  con  mned  t^'^  '•;J^^^'  „  .^^^,,^,  pneumonia,  the  te.n- 
,U.fiTves<rnce  is  called  lysis;  a.    mu>.  a  ,.„„valescence  may 

,,n.ture  falls  sud.lenly,  by  c"S^-  ., ,  '  ,/  J,  ,..,.,.  of  the  symptoms 
l  interrupted  '^X/^'^P^^  ''  ^  ^1  ,  I  .l.^urs  before  the  ten.perature 
.,f  the  prin.ary  m\vvUou  .  it  t  .        ar  ^  relapse. 

l,,s  reached  the  normal  l-;-  -.;;'.     ,       .,•  i„r,,tion  p'ncral  y  called 
:,  Persisting  infection.  ;'  '„  "/.....tinnanc.e.  dnrin,  the  ^vhole 

chronic,  which  .>  <1';'7'-  V"''^    ,  ,  ^  '.'    '  .^s  to  be  at  work.     FAan.ples 

'>'■  ^^ ''■"•''  ''""•  ''"■  '"''"  n,    i,;  tErcul..sis,  svphilis,  etc.,  as  wc' 1 

..f  „.i,  type  of  di>case  arc  1""  ^  ^  ^    !^^^'  „,;„:,;,  pyu.cnic  coco. 
.,,   in   ...■casional   cases  ot    n.tection    ">/"\    ■   .„  .^  ,  i.,,^.,  ,,nd  we  note 

;  t  line,  the  -^^^^^^-^YV?::^:^tZ^^  U>  .Uvide  these  inf..- 
,n  exacerbation.    (  Inncally ...t  •>  J    "  t"  ^^^^  ,,^  ,„,. 

ti..n>  into  stages,  as  ,s  .l-ne  n.  >      '   '^^    '^Vh,,,  ,,,n  anu.n,  dinic.an. 
nc-ss  in  tlu-  pre-ent  connect.....  '""';\;  *  ".,,•„,,  i„t.,  <lis..se. 
S.is  .node  of  .lassificat...,,  ^^[^^^^  'L'     "'^ittent  h.rectio..,  as  ,t 
(■l,..ely  allied  to  tlu-  abuN c  ""   *'  jf  „„.rc- than  one  orj^an.s.n 

is  s..cn  in  rl.eu...atisn.;  at  P"-''  ^^^^^i  '  ,  ;  't.-ristic  to  which  we  refer 
,v..r..  .bl..  to  .....se  th.s  "'''•i';  ;,  f^J^,;  .,  ,„n,pl.-te  rc.-overy  or  total 
l,,re.  is  that  there  .s  >n.t  ^v.th    leU r       -  m  I^.^    ^^^^^^^^^  ,.^^,^^,,,^,  „,, 

,l,..tructionotthcor,>:amMn;tl.e!:trm 

.  .  ,,,,..,.  ,..U  .,  ,1.0  ,.r..s..n,  .inu. ...  sp..k  ;;[. I-'--- i-'l;;;! 

s;:tn:'rn.:xi::;;.;;;:h..n...-...of .....wo..... 


TllERMOdKXESlH  AND  PYREXIA 


147 


from  time  to  tiiiu-  into  an  iitiitc  form  of  inlcctioii.  The  gmiis  appvar 
lo  work  fotiipiirativi  1 .  slowly  and  to  di'Viloj)  ncitlicr  a  very  lii>;li  (l(j,'ree 
"I  intoxication  nor  so  active  a  resistance  i  i  ilic  part  of  the  hody  as 
«.■  lire  accustomed  to  see  in  the  acute  infections.  We  now  recognize 
more  and  mi)re  f  ly  the  frecinency  of  latent  infection,  of  conditions,  that 
i>,  in  whicli  for  moinli>  and  it  may  he  years,  puthop-nic  hacteria  (ht- 
-i>t  in  the  tissues  or  cavities  of  the  hody,  setting'  up  no  disturhance, 
liiit  capahle  at  any  moment  of  so  dointc.  We  may  instaixc  the  now 
u ill-known  "typhoid  carriers." 

Subinfection.  This  term  indicates  a  -li^dit  de^'ree  of  infection  such 
:i-  is  e.\pressed  hy  the  presence  of  liactcria  in  tiic  Mood,  which  arc  not 
potent  ciiouj,'h  to  cause  ^ross  symptoms  of  infection,  yet  which  do 
nrtiially  wear  out  the  cells  whose  duty  it  is  to  comhat  with  and  kill 
iliem.  Normally,  of  course,  hacteria  are  heinj;  carried  away  from  the 
intestine  and  killed  in  the  mesenteric  nodes  and  in  the  liver;  when,  in 
addition  to  this  constant  action,  we  find  that  hacteria  are  locally  active, 
and  that  there  is  a  local  inflamination  in  the  howcl,  if  we  examine  the 
Mi.Miiteric  node  cell:;  and  the  liver  cells  we  find  renmants  of  bacteria, 
(iltin  mere  granules;  the  constant  destruction  of  more  than  orilinary 
iniinhers  of  these  means  the  more  than  ordinary  wear  and  tear  upon 
'  icll>;  liver  cells,  for  instance,  are  thus  the  more  quickly  destroyed, 
1  in  many  cases  of  cirrhosis  of  the  liver,  we  helieve  this  is  a  causae  of 
c(.iidition,  thoiish  not  the  only  one.  It  is  not  necessary  that  the 
Ml  miniums  he  verv  virulent;  we  think,  in  fact,  that  the  ordinary  bac- 
t'  rill  of  the  intestinal  tract  can  and  often  do  constitute  the  agent  in 
till  M'  instances  of  snhinfectiori. 

Terminal  Infection.  -It  must  have  struck  everyone  who  has  had 
'  ■ !  niodcrate  amount  of  e.\])ericnce  at  the  post  mortem  table  that 
111  I  -  of  chronic  disease,  such  as  heart  disease,  where  death  has  been 
i;m  ;,iiil,  there  is  frequently  present  some  infection,  such  as  a  lobular 
•  '  Minoiiia,  or  turbidity,  from  infection,  of  a  lonj,'-present  ascites,  or 
'  i  ir  not.  These  infections  we  call  terminal;  and  they  arise  not  so  much 
!•  \iriilcncc  of  the  orfianism  as  by  weakness  of  the  body.  We  mean 
'  I'-iLriiiite  by  the  words  "tcrininal  infection"  those  cases  in  which 
'■■  n;is(.ii  ,,f  failing  vitality  a  germ,  powerless  at  ordinary  times,  is 
"  'ilcd  to  fasten  ni)on  the  tissues  and  set  up  an  acute  infiammation. 
"  '  :  II  process  means  that  by  reason  of  weakness  of  the  body,  a  sub- 
i  i;  linn  becomes  an  acut«'  infection,  the  terminal  infection  being  set 
I'i'  .  the  chance  microorganism  which  may  be  temporarily  circulating 
i'i    '  I'  blood. 


Ilii 
ail' 

.1,, 


THERMOGENESIS    AND  PYREXIA 


fei 


F.rexla  is  a  heightened  bodily  temjjerature;   the  state  of  body  in 
a  p\rt!xia  exists,  with  all  its  concomitants,  we  shall  call  the 


'".  state  or,  briefly,  fever. 


y^m^-.Ti'r'- 


148 


THE  MORBID  AND  REACTIVE  PROCESSES 


Heat  Production.     Hont  is  liberatcl  from  the  organis.n  under  the 
''''I't^'bS;  /.  e.,  from  the  re.on.bination  of  .lissociated  food- 

Metahohs,n   breaks   .own   ^1- J-eU   s.  tou     a  ud^  ^  J^ 
obtain.!  conU.n.e  with  own^^jnu.^^^  ,„„,  ^,^  the 

Fever  is  accomi.anio.1  by  in(  rta>ul       a  I  .^ 

intake  of  food  is  generally  'l"';"-  ^   /      .  JJ^^  be  .h.e  mainly  to 
than  norn.al.  tins  increased  heat    '■'•"l  I     "     y,;!^,^  ,„,,.  ,,,u  think  of 

ti.sne  disintegration  an.l  <7"';'*;;;  '.JJ;  ,    !     ■,  , '-hnrned  up.'' 
thefebrilestateasonen.^vln.  .    he     >s«  U  ^^^^^^^  ^^^^j  ^^^ 

Heat  Discharge.-- Heat  s  lost  f"' ";"''";;,„„,.  ,,f  ^xereta.  The 
evaporation  from  t  -  ^  7;-'\^J  ,1^;  v'l^nl^rature  lowered  by 
discharge  may  be  mereasul,  «'";"'-.         -j  „^ount  of  sweat.  an*l 

which  the  dog  unable  to  P^'7\'-,%^:;;;VS  calories,  a  calory  being  the 
We  express  hent  freciuently  m  t^^^^^^'  ''j"*,^.^  ^  r  at  normal 
amount  of  heat  -^^^^  ^  dS  S>n  f^^m  the  human  body, 
atmospheric  pressure.  .<t  J'  .\<;'\;  .\^  „„,,  f,,ees,  less  than  4  per  cent, 
less  than  2  per  cent  is  lost  ^^^''J^^^^l^^  f,,„,  the  lungs,  l.^>  per 
in  tlu-  oxpire.1  air.  .  per  ^^  "  [^ ,/  ^  '^  p,,  eent.  is  lost  by  radia- 
eent.  in  evai)oration  from  the  skin,  ^^n  u   /.)  pir 

tion  and  con.luction  from  the  '>;;;^>  ™^^^     j,^  ,.^„tact  with  the  body, 
The  lower  the  t-ni-J'. t'- o   tl     m  d  un   n   ^^^^^^^^^^^^^^  ^^  ^.^^^^ 

;l;:/roft  Wyrlndt  airt  :o  .tnratedUh  moisture  that 

S^ltion  is  prevented,  t'^/^  >-;;Xr'Lr  fheat  .lischarge 
In  spite  of  the  variation  ot  >  ■«  *  J'    '"     .'    ;,„„.,.,oode.l  animal  is 
at  different  times.  tl';\ tenipc|aturt         t  .r  ^^^^^^^^^^^ 

verv  constant  (save  in  hiliernating  animals '"""'-  ,      ,        ^        i 

:old-bloo.led  animals  Iwive  a  t-'P-';  l^-,-       f ,    !^'    ^l^niperature 
,ne<linm  (poikilothemuc).     » ''^;  "  l'^    \  1     li     t  .nperature  if  107.;^ 

a   <,msla„t    U.,nporat.,r,.    '''""f ""'",;  'Vt,  ,  '  t to  .cts  of  sensor, 
„„ve>.  one  I"'   ™'  7„''„™'^^^^^^^    „«,  or  Lnvors  the  Inxlily  te.upera- 

":,r^";  *or.,  tL'™:  "o:::.  roa»,„ ...  »up,»s.  ,i,..  .>«=  are » *« 


FEVER,  THE  FEBRILE  STATE 


149 


liraiii,  or  tin-  cord,  «»r  in  iMitli,  evils,  some  of  which  on  stimulation  cause 
ill)  iiii  reasod  prtMhiction  of  litiit,  others  an  increased  loss  of  heat;  these 
cells  arc  aheetetl  in  various  ways,  for  example,  reflexly,  or  by  the  tem- 
perature of  the  circnlatiuK  1)I(mh1,  or  by  sul)stances  in  the  circulating 
Mood  that  act  upon  them.  So  perfect  is  the  result  that  it  seems  hard 
to  think  «)f  the  mechanism  otherwise  than  as  controllei'  hy  one  centre 
or  a  pair  of  closely  connected  centres.  It  must  always  be  rememl)ered 
tliat  the  thermometer  jjives  us  information  only  as  to  the  balance  or 
resultant  l)ctween  heat  income  and  heat  expenditure  at  a  given  moment 
In  a  particular  i)art  of  the  b(Kly;  we  Rain,  therefore,  by  the  use  of  this 
instrument,  no  accurate  measurcnuMit  of  the  amount  of  heat  developetl 
or  lost. 


FEVER,  THE  FEBRILE  STATE 

Fever,  or  the  febrile  state,  is  the  train  of  symptoms  and  changes  in 
ilic  orjjanism  which  constitutes  the  reaction  to  infection,  which  changes, 
iiltliough  associated  with  increased  heat  j)rcKluction,  may  occur  with  or 
without  rise  of  temperature  (be  febrile  or  afebrile),  and  the  rise  of  tem- 
piniture  itself  is  best  known  as  pyrexia.  The  febrile  state  is  dissociated 
u  itli  changes  in  the  circulatory,  nervous,  muscular,  respiratory ,  digestive 
Mild  "xcretory  systems,  which  we  shall  take  up  in  order. 

Pyrexia. — In  an  infection  we  can  frequently  recognize  the  fervescent 
or  pyrogenetic,  the  continued  febrile,  and  th;'  cefervescent  stages;  the 
\a-x  iiaiiied  may  be  very  short,  the  temperature  descending  sharply, 
liy  crisis,  or  gradually,  by  lysis. 

We  are  wont  to  distinguish  the  varieties  of  fever  as  continued,  in 
"liiiji  the  changes  between  maxiimim  and  minimum  are  as  sHght  as 
III  litalth,  but  at  a  higher  level;  as  remittent,  where  the  changes  in  a  day 
iiiiy  range  over  several  degrees,  as  happens  in  bacteriemia,  suppura- 
ti'ii,  and  tuberculosis  with  secondary  infection;  and  as  intermittent, 
uliirc  a  succession  of  fel>rile  attacks,  each  with  its  fervescent,  con- 
tiiiicil,  and  defcrvescent  periods,  occur  separated  by  a  continuous 
ill'  rval  of  normal  temperature  of  a  day's  or  more  duration — as  in 
III  iliria.  Where  several  days  elapse  the  fever  is  called  recunent,  as 
ii    11  l;i])sing  fever. 

The  Associated  Disturbances.— Disturbance  in  the  Nervous  System. — 
'  ''  /.v  and  Chilly  Seiimthns. — It  happens  often  in  the  fervescent  stage 
"I  inttctions  that  tlie  patient  feels  cold,  the  teeth  chatter,  and  yet, 
i  iiiiUi,  tile  surface  nuiy  be  hotter  than  normal,  and  the  temperature 
'  '  i.  and  increasing  in  height.  The  face  and  extremities  may  be  pale. 
1 '  iiallor  or  local  anemia  suggests  that  the  blood  is  attracted  to  other 
'  "  us,  making  a  corresponding  congestion  so'^^nvherc,  and  that  there 
'-  -inrage  of  heat  in  the  body  for  the  time.  The  chill  is  evidently 
'  iiunicnon  incited  from  the  central  nervous  system;  in  fact,  the 
<     ;  may  occur  without  exposure  to  cold  or  infection,  in  which  case  it 


^r  .  S^^Pffsm'   'tSs 


jf 


150  TlIK  MOliUlD  ASD  REACTIVE  I'ROCESSES 

appear,  to  b. .....Uy  a  ,>art  ..f  ti.  ^''-^'i^;;;;;;,;:!;::;  •  ^^ir  • 

...illary  .■..ntn...t...s  ;;-;'-;;.       l:,  .^t......  .la-  ...ti .ur- 

riL'or;  ii.  fact.  .-i-poMn^'  mii>.'U->  >>"<  ""-..i ..     '.  .  •       •     ;,{. 

1 7' '';^;;:r''v,:;*"r;:;.s::':;t;?""  >"!>»-•"■■ :- 

(Ti.tral  nmous  sNstfin.     Hust  at.   1^  ,  hea.lad..-,  im- 

„r  iiotu-e  till-  pasbap   ot  .xtnt.i.  cp  j^  ,  ^    ,„, 

.onsi-kT  that  the^e  phen..nu-Ma  arc    '';,;    "^;' ^    ./^  ^  ,  ..rtain  toxin> 
the  c«-lls  ..f  the  l.raiti  an.l  conl.  c^Kriall    a^  m  "^  ';',., . 
;;:...  a  direct  anmity  f.-r  the  nerve  Ml  Ik;;  >     -»  '  r^      .  ;„  ,,„,„,,. 
Disturbance  in  the  Circulatory  System       I ht>   I  V,,,,^^^.., 

isa..oonM.nnie.ll.yanK.rkc.hm-rcj.    m        ^      i  >  ^^  ^^^^^^^  ^^^_,^^._  ^j^, 

l.y  incrcase.1  pulse  rate.     ^^^'Vi     .ti    ,    .  .1 'lowcre.!  M-....!   pressure. 
.Hcrotis,.,.  iu.licati,.K  artena    .hlatatum   a.       Um   n  ^^_^^ 

.,r  a  full  l.uun,lin,  pulse,  so  that  .t  is  eve    .t  U  ■  ""^^^  .,•    ,;,,,, 

h,to  the  sthenic  -  those  ^'I'^'^'^'^'^f^^^''  ,,  ^  '"i'nic     T»'<'-  '^^''''- 
..specially  circulato^  encr^-     a.al    he     .    n.r>.  asthe^     ^^_^^^     ^^^  .^,^ 

mu.ations  are  usua  1>    n.a.l.     "  '>     '•     ,       ^,j  f,,,.t„rs  th  '  our 

is  atVecte.1  in  any  pvcn  ease  U>  so  la.       '  '         ,     ^„„,,,  ,,„,ever. 

de<luc.ti..us  are  not  of  nu.ch  value     U.  '^  ^      '    ,,^,^,  ^,,^  ,,Hiac 

is  that  n.any  f.x.ns  oi  ".''^■•■^'^•'■,  ''^ '^   ,^,  "  'J'      „t  ,1,.  nerves  Nvhieh 

cause  a  I.  -is  ot  red  <'»nu-^"'^.'  .♦,„,,,i,wi  Kv  a  .l^t  net  nierease 

variable.  Mo.t  kinds  of  „>leet,on  j'  «;  ^^^^  f  J  Hk  tvphoi.l  fever. 
i„  the  leukocytes  in  the  peripheral  '•''"f ' ;"\;;'  V',  ,,;•,„,,  „  rapid 
are  atten.-d  by  a  h>werin,  of  tbe  mini  .  ■;-^,;  ;^'  ;,,^,J,,,„  [,. 
Hse  i.  the  leukocyte  count  "'''"•^  '^  ^  ^^,:^,  ;,  ,  ',  ,' ,..,„lary  infec- 
superNcned;  but  it  must  also  u-  [^••'''  '*;'!:,;  ^,,^,  ,,,,ti„n  of  tl. 
tion  may  supervene  vvithout  a  ''■;'1^"''>!;^'  j  '  \'.;  .' j  .,,,e  of  a  leuk.- 
h,,!v  r..av  be  insuHicient;  m  >u.h  a  case,  t  h  y'^>  '"^^'^^^^  prof^nostir 
cytosis  in  the  pres.  me  ..t  .    '  .' """^>  ,  .,,,.  ,,ecuston.e(l  to  fin 


FEVEIt,  ntK  FFAiklLK    ^M //; 


101 


liifk  iif  rcfictioii  (til  tlif  |nirt  of  tin-  |>atiti,l.  Tin  nun  ,i-  in  the  while 
■  I'll  is  usiihIIn  ill  tin-  polyiiiiclcar  ii  acuti-  «'it>«-^.  in  tin-  I  r>li<wvti's 
ill  the  slower,  Ifss  iiitciisf  iiilVi'tioiis,  such  a^  tuii»T<-iil(.>i»,  I  in  tlit 
iii-^iii(>ii|iil(-  ill  <'(Ttaiii  stat«'s  uIkto  iiiiin!Jil  parasiti  art- i  ><iit,  nd 
in  icrtaiii  infections  of  tla-  skin  ami  also  m  w  li(M>|)iii):-.  uu^l 

Disturbance  in  Respiration.  -The  n-spmitory  iiiu\ciiu-nt  i-  i|iiickci'  i 
III  inlirtions.  This  (|uickcf;inj;  i  hnnifrlit  !il>oiit  liv  aiiytiiinjr  win  ' 
iiicrcd  rs  tin   ti'iiijHTaturc  of  the     i"iMl  hitiliin^;  the  respiratorv   ceiitr' 

The  rapid  l>i<iithin);  has  th'  fleet  oi  iiicrrii -iiij;  the  cxaixirati  n  in  th- 
Innjrs,  anii  iliHiisin^  more  liciit  than  n-  ul  iHcaiise  iii'r--  nir  is  Ix-int: 
vvariued.     The  iiu  reaseil  tein  leralure  oi   an   infi-ctfd  patunt  a     1   tin 

lifiMtion  itself  fa\or  increasi    .f  in*  laholisii!.  and  (ho  im     iiM-of  \  utali- 

M''-;ni  I    ids  to  increaMd  tei    j.n  i  I  carbon  di"\idc  ='i  tht-  hiKxl,  i<!  ich, 

in  tin  ,  is  again  one  of  tlie  iinportiint  «'auscM  of  '       incrcaMtl  r;i'f  of 

!i  -piriirinn. 

:  isturbances  in  the  Urinary  System.     '1  i>e  ctFect  of  P      r  i-  i..  din      ish 

water  of  the  nriiic,  and  the  chlnridcs  and  phosjiiiates.  and  t<j  m- 


n :,  (•  file  decree  of  coloratHii,  tin   urea,  the  uric  aei.     th 
iiiid  i!ii    [Mitii  diiin  salts,     Tlie  diinimitioii  in  \\at«T  i- 
li\M      1  liliNH!  pressiirs'  an.:   partly  to  the  increased  - 
-liii    iiid  e\apor:i'ici  fniiii   the  liiii>;s;  the  diiniiiut'oi 
ii'i  -utisfactorily  expla'neii.    The  iiK  reas.   in  iiot    rsinin 
'111   lar.ue  miinltcr  of  t  d  cells  ihat  1      c  Ik-ci    iiroi-     •  np;  tin 
.''\>    acid  iind  otln         'oj.'cnoiis  dcii>ati\c',  art-  ti        isnlt  i 


■ti, 


Tiou  rn 
chlo'-'U 

ilts  isi    mf 


:<} 

^s 


"ii-rn  ti  it  i-  more  acn\  i  tian  u>ual  and  i  the  hn 
tiiiis,  \\ii,'-h  protci  ;-  an  ;.ot  all  food  an'i  reser\t' 
1  irtly  tlu,  ■■  of  the  tissue.-,  in  this  sense,  <  iifcti 
ip"  the  patient. 

Ill  most  severe  inic-  tions  the  urine  conta' 
:'v  tile  seat  of  a  cloudy  swelling:  '>r  worse: 
tin    kidney  is  prol)abl.\   due  ti>  <li:iiiijt 
'    tiic  ti'   ins  tlicinselves  .;nd  iii  i.         the  p^ 
integration.    This  state  of  the  m      ■  i>  L'ei 
alimnunuria,"  and  the  iirin.    M-cn'        dnr- 
toxic  to  animals;  the  luxin        on 
'    and  tiic>'  damage  the  kidi;        .n  tiieir 


o-.inu 
jiiatcr 
m  'itet 


iir  a  a-  'l 

iiieta ;  >- 

'if  pro- 

liiit  iire 

••l.iir 


-  alhuinin,  .liid  the  kii 

>  l)ar'  ichymatoiis  cL 

nKighi  on  ti      cpitht-itui.i 

■■--     'i«  us  prod  11" '    nf  tissu'' 

lily  (k'scrih-  "febn  a 

(Ii         -ctioii  is 

.IT         ■■  in  the 


)isturbance  of  the  Digestive  S>  icm.     It  i-  <     u  th.r 

'lite  aim  dista.->tc  for  f(  od  arr  ;  (•cjiu  lit  re>t.  intectio    ,  • 

\i'     i'i|og\  of  tlic  pr(H(~>  is  not  y.-     'lear;  the  ;.'i;    liiihir  secretii 

'\  iiess  (if  tii(   mc  !ith  and  t 


s   Ol 


ned  in  am(   iiit,  as  i>  seen  in  tin 
'  -sory  dip -tive  glands,  in  fact 
I'liced  by  ^he  toxins,  and  clciidy 
Tespondir       ick  of  efficiency  of  tii 
tie  Cause?     r  Pjrrtxia. — The  n  - 
'lire  is  ino     Kin,  but  there.     ■ 
:re  iiK  ';ti(cii.     1  he  uifectivt    iiu' 
■  \ia  can    •    irnduced  exj>erin    nU' 


il   the  l'   lids  of  the  body,  are 
-welling        -ilts  with,  no  doubt, 
'  gh'    d  i        ,ie  time  being, 
pre  'M  cause  of  febrile  tem- 

"^     '!        auses  of  pyrexia  which 
through  their  toxins,  for 
■■  1}         ns,  as  well  as  by  enzymes 


.| 


im^^^^^ 


1o2  THE  MORBID  AND  REACTIVE  PROCESfiES 

lu.nu.rrhaL'f,  or  up<.n  tlu-  in  i.tu.n  ..t  l.lo.«l  mt..  tin-  >>. Um     r  up    ' 
The  s  erile  extracts  of  tissues  or  t.ssi.e  jv.urs  ""•;""'"•       '^'  nn^ 

:;xii::-rri;;j;:;;:l";;r;:;;^;;f.^^ 
;;-::;r;L;;"Sof:!:;;^;^:^t.;.n>eJ.re.a.^ 

t  !::i!;  olVltlu-r  otder.    We  l.ay.  alrea.l>- refe^ed  to  tl.e  .^^^^^ 
evidenee  of  the  existence  of  this  f..rn..     Chnieally  it  i.  to  tu  ^'".|>-^/ 
a     'certain  injuries  to  the  central  nervous  system    and  1--    '>   ^^ 
XI  lains  the  px  exia  of  su.otroke.    We  are  not  yet  able  to  supph  tlie 
'  la  nti  ns  mlssarv  for  the  .ronpin^  to.r.ther  of  all  these yaryu.g  cases. 
i:;ftheiSive,th;enzyn.e.andthetissue-extract.ea^^^^ 

what  similar,  and  all  of  these  are  cases  where  reaction  lea*  1^  to  the    ro 
dSr  of  "itihoclies ;  just  as  hiHanumition  IS  the  reaction^ 

an  ar^  t  exceptio,;'.  in  whi<h  death  occurs  in  l.yi-n>y™.  "-y  be 
!.L  in  whid.  a  specific  action  on  the  heat  c-entre  ,s  pn.d  c^ 

It  is  perhaps  unwise  t<.  attempt  to  hn<l  a  purpose  for  eMr>  morl) 
ph    .omlnon  when  our  ignorance  is  still  so  a  nsn.al;  "-'-  ^^  -^ 
the  fehrile  state,  knowiuf:  how  iucr.-ascd  heat  stimulates  the  cdb  to 

:J  a:^;Sve  metld-oUsm.  it  is  .lilhcult  m.t  J-'/l'^^;^^  ^HhTn  ,^^ 
hoth  the  nervous  disturbances  l.^adrnj,'  to  heightened  h)  iil>  t<."'P;j' 
U  e  .u  r direot  action  of  the  toxins  upon  indivi.lual  t-sues.  m  ^ict. 
a  Uhc  phenomena  of  fever,  lead  up  to  and  favor  that  -<r;:"-'^^^  j^ 
.,f  the  bo,iy  cells  which  results  in  the  produ.l.on  ot  ^i;;^^^  '  "^^  ^  ,^ 
and  that  at  an  accclcrate.l  rate,  so  that  therebj  the  spc.bc  toxins 
are  neutralized  and  recovery  is  ailed. 


IMMUNITY 

In  the  course  of  infections  and  <"---,-*  "Pb>-:;5"»;;;^^^ 
substances,  the  body  .leveU.ps  certain  antibodies  b>  ^^'  •^'' ^''^  ^f^^^. 
are  neutralized,  so  that  the  d.sturl.ance  '7•"^^t«,«^:'f  •,  *  ;  J  J 
nroccss  of  immunization.    It  has  already  been  indicate.1  that  the  bm 

.rr^rt  in  immunity.,  absolute  or  relative,  to  deleterious  outside  rn« 
Jl  of  many  kinds,  which  immunity  is  only  another  name  for  the 


em 


IMMUNITY 


153 


acciistoinance  to  surroundings;  the  body,  furtlier,  lias  immunity  wliieli 
is  inherited.  We  know  of  certain  acquisitions  of  immunity  which  are 
};ra(hial;  and  when  we  study  the  question  of  immunity  experimentally, 
it  is  only  those  cases  in  which  the  imnninity  is  jjroduced  in  the  course 
of  a  short  time  that  lend  themselves  to  our  experimental  study.  We 
thus  know  little  about  imniunity,  save  as  it  is  produced  in  connection 
with  some  toxins,  enzymes,  and  tissue  juices. 

Non-specific  Immunity.  -In  our  discussion  of  the  defences  of  the 
iinily  we  i)ointed  out  that  if  microbes  of  various  orders  be  intnxluced 
ill  small  nimibers  into  tlie  tissues,  unless  they  be  of  extraordinary  viru- 
lence, they  are  destroyed  in  a  very  short  time.  In  other  words,  the 
cells  of  the  body  have  a  defensive  power  which  may  be  used  indifferently 
Mi;ainst  various  intruders.  And  even  where  we  deal  with  the  devej- 
npmeiit  of  an  acute  specific  disease,  we  notice  this  strikiuR  fact,  that 
the  microbes  of  that  disease  are  not  to  be  found  growing  throughout  the 
uhole  body.  Take,  for  example,  a  case  of  malignant  endocarditis;  the 
\ try  fact  that  the  heart  valves  arc  singled  out,  is  in  itself  an  indication 
lliiit  the  microbes,  streptococci,  or  what  not,  ha\e  been  circulating 
ill  the  blood,  and  the  very  nature  of  this  disease  necessitates  that 
the  microbes  are  from  time  to  time  being  swei)t  ofY  the  valves  into  the 
Mood  stream  and  carried  now  to  this,  now  to  that  organ  elsewhere 
ill  the  body.  But  the  remarkable  fact  is  that  in  such  cases  we  never 
fiiiil  abscesses  forming  in  the  nuiscles,  and  very  rarely  in  the  brain, 
«r  ill  the  nuicous  membrane  of  the  alimentary  cimal;  aiid  yet  all  these 
ti>sncs  have  an  abundant  blood  supply.  Numerous  similar  instances 
will  l)e  tailed  to  mind,  and  the  only  conclusion  that  we  can  draw  is  that 
uhilf  certain  tissues  or  organs  are  peculiarly  susceptible  to  the  inroad 
of  one  or  other  species  of  bacteria,  coincidently  f)ther  tissues  are  char- 
:i<  tcristically  insusceptible,  or,  in  other  words,  are  engaged  in  destroying 
tlir.e  organisms  and  preventing  tlnir  growth,  or  in  yet  other  words, 
|"'>>css  a  local  innnunity.  The  muscular  tissue  or  the  endothelium  of 
I  lie  \  essels  supplying  the  muscles  may  hv  cited  as  a  well-marked  example 
"1  tins  non-specific  immunity,  because  no  matter  what  bacteria  attack 
'!"  Ixxjy  they  <lo  not  make  a  foothold  here,  bacterial  infections  of  the 
iiiiiMlf  being  very  rare.  We  mention  tliese  facts  because  it  seems  that 
tin-  ( apacity  on  the  part  of  tliese  tissues  of  destroying  bacteria,  without 
■ni.N  i.revious  apparent  education,  must  be  the  fo'undation  upon  which 
I  'milt  or  developed  the  sfjcciiic  immunity  toward  particular  species 
"  I'M'ifria,  which  we  shall  immediately  discuss.  Or,  otherwise,  the 
'I'  I  Inpiiicnt  of  specific  immunity  is  not  to  be  regarded  as  a  new  property 
"I  Mqiiireinent,  but  as  an  exaltation  of  properties  already  possessed 
I  'Ik  tissues,  and  if  this  be  so,  it  must  be  kept  in  mind  that  in  each 
'I'  iM>  that  attacks  the  body  this  non-specific  immunity  is  constantly 
■I'  "rk,  liand  in  hand  with  the  specific  immunity  that  is  gradually 
I"     -  ilt'vcloned. 

Immunity  against  Substances  of  Known  Constitution.— It  is  known 
''      liie  so-called  "arsenic  eaters"  of  Styria  can,  after  a  few  years' 


1.-.4 


Tilt:    MORBID  AM)  RKM'TIVI-:   PROCESSES 


a.l.licti,...,  (■..ns.mu-  witl...i.t  ill  cUV.ts  four  ti.iu-s  tl.e  onlinary  latal 
.l,.s.-  <.f  tlu-  .Ir.m,  ami  vvl.iU-  tins  l.as  n..t  lurn  .•..nhniuMJ  with  annimls 
M.-vortiu-lrss.  tiun-  is  .-vLlnur  ui  a  (vrtai..  !,Ta.lo  ot  ..nmumty  that 
,ai.  ho  cui.f.rrr.l  ....  th......     If  a.,  arsn.ical  salt  h,;  inj.rte.l  int..  tht 

,,..rit..iK.uin  in  s,.s,.c..si....  or  soh.ti.....  a  fatal  <los.-  is  acronipanu-.l  hy 

a  .liminntio..  of  tl.e  U-.iko.ytcs  that  are  f.......l  so  almmlantly  in  the 

IKTitoiual  fh.i.l     a  ..i^ativ.-  ch.-.niotaxis  is  ..xcitHl.    It  the  .lose  he  not 
fatal,  there  is  at  first  a  re.l.ution.  f..ll..we.l  l.y  a  fireat  increase  in  the 
nninh.T  of  tl.e  l.nko.vtes.  so  that  tl.e  ,.erit..neal  Hni.l  may  appear  nnlky, 
an.l  tl.e  le.ik.K.vt..sis  in  tl.e  .ir.nlatinK  hl.....l  hee..ines  very  evi.lent. 

Whether  a  siispensi..ii  ..r  a  solution  of  arsenie  he  en.pU.yed,  the   .•iik..- 
evtes  are  f...n  .1  t..  take  it  up,  an.l  the  lar^.-r  the  .l..se,  provi.le.l  it  he 
not  fatal,  the  more  prono.m.v.l  is  tl.e  leukoeytie  increase      In  tune, 
fixe.l  phagocytes  also  take  np  p..rti<ms  ..f  th.^^  arse.i.c    which,  m  fact, 
spciallv  Uni.ls  to  fin.l  its  way  t..  tl.e  liver     The  fatal  efTec-  s  are  evi- 
.lentlv  \vn.uf,ht  up....  the  nervous  tissue,  which  is  susceptible  to  such 

an  extent  that  ..ne  ..nc-l.u...lre.itl.  ..f  tl.e  sul.cntane..us  d..se  is  fatal 
if  ini.-cte.l  into  tl.e  l.rai...     I..  pr.Mlu.iuf;  immunity,  a  rahhit  is  taken 
,.f  such  1.0.IV  weight  that  10  <•.<■.  ..f  a  Kiven  s,.lut...n  pr...lu.rs  .leath  in 
fortv-eifjht  iu.urs;  2  c.c.  of  this  soluti..n  is  inj.rtcl  at  night,  t..llowe.l 
l.v  io  c.c.  (the  fatal  .l..se)  n.-xt  morning:  hut  i...  ill  results  ensue     Arsenic 
is"  slowlv  eliminatnl;  the  a.iin.al  has  12  .•.<■•     nu.re  than  a  fatal  .lose 
in  its  b(..lv;  .leath  .Iocs  not  ....•ur  hecaus.-  the  first  .l..se  has  («x<ite.l  an 

excess  of  feuk..c^  tes,  wln.li  an-,  so  to  sp.ak,  Ix  ing  m  wait  f..r  the  second 
.lose  to  he  inj.-."te.l.    This  is,  if  i...t  tr.ie  immunity,  at  least  a  tj.rm  ot 
positive  proticti..!.,   comparable   t..  the   pr..tecti..n   t..  be  spoken  ot 
later  in  .lis.ussing  "  Issaelfs  r.'sistan.-.-  p.-ri...!"  an.l  to  tne  n..n-specihc 
iinmunitv  that  has  just  been  .liscusse.1.    Hut  there  is  nmre  to  be  sau 
If  after  six  ..r  .iu'ht  .lavs  this  animal  be  bl.-.l,  the  serum  (.f  the  bl..o.l  i» 
f..un.l  t..  have  ac.p.ired  a  new  pn-i-ertx  ;  S  c.'.  ..f  it,  injectc.l  mt..  a  fresh 
rabbit  aU.ng  uith,  or  slightly  before  a  minimal  fatal  .l..se  ..t  arsenie, 
i.revents  the  .l.-atl.  ..f  the  animal.    This  prevent....!  is  the  e..n  erring  on 

tl.e  fr.-sh  animal  of  passive  immunity;  .i  substance  n..t  ...a.  e  by  the 
animal  itself,  but  introduced  int..  its  b...ly,  acts  as  an  ai.tid..tt-ai.ls 
the  b...lv  tissues  in  ...■utrali/.ing  ..r  .l.>tr..yi.ig  the  p..is..n.     Ihe  scrun. 
of  tl.e  a.tivelv  i...muni/e.l  animal  contains  s..metl.ing  that  it  <J<1  n..t 
entail.  iK^fori-  tl.e  imn.uni/.ation.     What  is  this  s..metlni.g/     We  d.. 
n..t  ki...w;  but  we  .1..  kiu.w  that  it  is  not  arsenic  containing,  is  not  a 
e.....binati..n  ..f  the  arsenic  an.l  the  cell  substance  of  the  animal.     Ih.- 

eell  substan.r  has  elaborate.!  s..inething  whi.  h  is  capable  of  combimng 
with  ..r  neutrali/ing  arsc.i.'.  so.n.thing  wl.i.h  is  capable  of  solution  n. 
th.-  serum,  an.l  ..f  remaining  in  it  for  eight  .lays  at  least.  We  are  m.t 
unaware  ..f  tl.e  criticism  t..  wl.i.h  th.-  interpretatu.n  is  open,  but  t..r 
.l.-arness,  we  r.-frain  fn.m  stating  th.-  full  argument  f..r  an.l  against. 

Immunization  against  Albtraiinoid  Vegetable  Poisons  Phytotoxins.- 
Th.n-  arc  eeftain  ^•egctab!..•  poison-  of  a  proteid  nature,  .listinct  fro... 
tl.e  alkaloi.ls  and  glueosides,  extr.-m.lx  t..xic,  to  wit,  abrm,  ncm,  robin, 


IMMUMTY 


l.V) 


and  otliors.  Of  riciii,  one  <;rjiiii  is  sufficient  U>  kill  a  niillinn  iiikI  a  lialf 
L'ninca-i)ij;s,  and  tliis  not  suddenly,  hnt  after  a  peritid  of  fdiir  or  five 
days,  siil)se(inent  to  wliieli  ledenia,  inflainniation,  and  necrosis  of  the 
lissnes  near  tlic  point  of  iiijction  set  in;  this  snf;j.'ests  the  existence  of 
,1  ferinent-Iike  action  with  formation  of  some  second  siitjstance  ahle 
to  act  upon  the  cell  substance.  If  animals  lie  fed  cautiously  upon 
-lowly  increasinj:  <loses  of  ricin,  they  ^mIu  such  inununity  that  they 
I  an  take  a  hundred  times  the  fatal  dose  w  ifh  iin|)unity,  and  hy  injt'ction 
il;f  immunity  can  be  made  so  active  that  they  can  take  five  thousand 
limes  the  fatal  dose.  If  the  serum  of  uch  an  animal  be  mixed  with 
I  lie  i)oison,  the  injection  of  the  mixture  into  an  animal  jjroduces  no  ill 
I  llVcts,  the  poison  bein;:  rendered  inert. 

Kicin  has  two  ])ro])erties— its  toxicity,  and  the  i)ower  in  toxic  doses 
!ii  cause  asglutination  of  the  blood  cor|)uscles;  outside  the  body  it  can 
■  ause  afifilutination  of  the  corpuscles;  but  by  the  action  of  pepsin  ami 
hydrochloric  acid  this  ajj;f;lutination  power  is  destroyed  without  the 
lio-iriti/  hell, II  diiiiinishcd.  Kither  ricin  is  a  mixture  of  lWo  sulistances, 
I'r,  what  is  more  likely,  it  consists  of  a  very  complex  molecule  which 
ran  underjio  sliultt  chemical  chanjie  without  its  specific  functions  beinj; 
iir>tr()yed.  We  may  assume  the  latter,  and  show  what  some  of  these 
iliaii;;es  are;  if  lieatcd  to  10(1°  ('.  for  two  hours,  it  loses  all  its  toxic 
pciuers,  yet  animals  treated  by  it  beet  nie  innnuni/ed.  I'he  so  modified 
ii'xin  (called  a  toxoid)  is  no  lon<;er  toxic,  but  is  capable  of  setting  up  t!.t.' 
'  iiaiii;es  in  the  body  necessary  to  the  formatioM  of  an  antibody.  If, 
a-aiii.  ricin  be  ailded  to  the  serum  of  an  imnumi/ed  an-'ial  with 
it-  antiricin,  so  that  the  mixture  is  inert  and  unable  to  i)roduce  toxic 
I  tl,  !s.  and  if  ilie  mixture  be  injected  into  an  animal  of  the  same  s[)ecies 
a-  yielded  tiie  antiricin.  it  still  has  the  jjower  of  proil  .  '  j;  active 
iiniiiunity;  from  this  it  is  evident  that  in  the  mixture  of  toxin  and 
antitoxin  the  toxin  is  not  destroyed. 

<  luce  an  animal  is  innnunized  ajjainst  ricin  it  may  be  bled  again  and 
a-.rin  and  the  blood  remains  antitoxic;  the  tissues  seem  to  have  acquired 
1* .  power  of  discharging  the  antitoxin,  so  that  it  does  not  seem  likely 
li  I  the  aiiTTicin  is  derived  from  the  ricin.  The  vast  jjreponderance 
lii  i|i"i'itity  of  the  antitoxin  over  the  toxin  also  tells  against  such  a 
-!i;  position.  Kvidaith/  the  untitoxin  is  a  suhstttticr  irholh/  new  to  the 
'  'II ism,  ])roducc(l  primarily  by  the  cells  as  a  reaction  to  the  presence, 
in  iliiui,  of  the  toxin. 

Immunization  against  Substances  of  Unknown  Const" Vu'on.- 
En;'ymes  and  Anti-enzymes.  If  a  foreign  en/yme  be  injected  ,  ' -dly 
ii  '  the  body,  a  tolerance  of  it  is  ac(|uiretl.  Iiy  means  o'  :  n  nti- 
I!  inc  which  is  formed.  For  example,  gaats  injected  wit.,  ennet 
I'!  Hc  a  serum  which  has  the  power  of  neutralizing  reiniet,  and  this 
'I  iiiiantitative  degree,  so  that  a  fixed  amount  of  senun  neutralizes 
■I  inite  iinioun*^  of  rf  nnet  of  a  known  strength.  Hut  just  as  an  animal 
"!  iiiized  against  a  cert.TJii  microrirganisni  is  siot  rendered  iinmime 
'"     liier,  although    closely  related,  microorganisms,  so  in  the   above 


f-.-.-ir*.  mofr-^sin  ■ 


156 


THE  Momnn  and  reactive  PRorEfiSES 


I  ?  I 


oiise  i\\v  hloiid  siTiim  will  not  lu-utralizf  tlu'  ctlVct  of  "  rcniu'ts"  .htainod 
from  i)Iaiit.s.  Thus  tlif  aiiti-ciizyino  is  strictly  spt'cific.  T!  ■  imici-ss 
.)f  iiiiinuiiiz:  tie  n  ajjainst  animal  and  vt'j;ftal)Ic  cnzynios  cenis  at 
first  sifilit  \  ,\  Ukc  the  pnurss  that  exists  in  innnnniza^ion  Utt^inst 
bacteria;  !  lit  'utc  is  this  important  ditlVrence,  that  the  de\v!"pn!cnt 
of  anti-ei  /Aiu<-  '.-,  limited.  The  supposed  reason  for  this  is  that  the 
anti-enz\  is  e  t  t  free  in  the  hody  stimulates  the  cells  to  set  free  an  anti- 
anti-enz\  :iie. 

Anti-en-'vi' es  exist  in  the  body  in  the  normal  state;  an  antirennin 
is  prese:'t  ii.  normal  i)!ood,  and  antii)ei)sin  exist>  in  the  stomach  mucosa, 
and  an  au'it'erment  to  tiie  dif;estive  action  of  the  i)aiicreas  can  be 
isolated  from  that  or^an.  If  it  were  not  for  these  antiferments  the 
j\iice  i)  the  stomach  would  (lif:est  the  coat  of  the  stomach  as  it  digests 
meat,  and  the  pancreas  would  digest  itself  in  life  as  it  does  after  death. 
Despit.  the  existence  of  antijjcptic  and  antidiastatic  enzymes,  they 
tannot  l)e  artificially  produced  by  the  use  of  jjcpsin  and  diastase,  nor 
d(H>s  the  injection  of  fibrin  ferment  result  in  the  pnxluction  of  an  anti- 
fibrin-ternient.  The  reason  for  this  jjrobably  is  that  the  enzymes  that 
are  produced  all  through  the  body  (for  pepsin,  iliastase,  and  fibrin 
ferment  can  be  i)roduce.l  by  the  cells  of  all  organs)  are  so  usual  to  the 
cells  that  they  (lo  not  excite  any  antagonistic  action. 

Toxins  and  Antitoxins.  One  of  the  early  discoveries  in  bacteriology 
was  that  of  the  bacteria-i)roduccd  toxins;  this  was  made  out  especially 
for  dii)htheria  and  tetanus  bacilli,  which  we  now  know  are  able  to 
produce  and  give  off  difVusil)le  toxins,  the  ectotoxins.  Most  bacteria 
produce  endotoxins,  which  are  not  dill'usible.  ''"he  injection  into  animals 
of  the  dilVusible  toxins  was  found  to  ])rodncc  innnunity;  the  serum  of 
an  animal,  so  hnnnmized,  contains  substances  which  neutralize  the 
diffusible  toxins,  either  outride  or  in  the  body,  and  these  are  the  anti- 
toxins of  medicine  and  comnicrce.  It  became  necessary  to  arrange  a 
standard  by  which  to  measure  these  antitoxins,  an<I  this  was  done  l)y 
determining  how  nnich  would  neutralize  the  unit  of  toxin,  which  is 
ihr  finiaUi'M  (iiiKiinif  flint  .siifficrs  to  kill  a  2')U-(iriim  giiineit-ijig  within  four 
(Iniis.  Tlic  production  of  antitoxin  is  a  vital  process,  while  the  neutrali- 
zation of  the  toxin  ai)pcars  to  be  j)urcly  a  chemical  one  of  the  nature 
of  a  loose  molecular  union;  toxin  by  itself  can  pass  through  gelatin 
hlters,  but  when  actctl  ui)on  by  antitoxin  fails  to  do  so,  that  is,  the 
lesultant  of  the  interaction  is  a  larger  (compound)  molecule. 

It  is  not  possible  to  define  the  term  toxin  accurately;  toxins  are 
substances  that  act  in  minute  doses,  that  diffuse  with  difficulty,  that 
are  i)roducts  of  cell  metatxilism,  and  that  iiave  not  yet  been  separated 
in  a  pure  state.  We  can  define  them  as  poisons  against  which  it  is 
possible  to  obtain  innnunity  by  the  jjroduction  of  antibodies,  and  we 
can  state  that  they  ajipear  to  be  colloids,  and  that  they  are  allied  to 
proteins,  but  are  not  proteins.  They  may,  however,  be  dissociation 
jirodiictr.  uf  proteins.  'iVhatever  toxins  be,  it  is  nevertheless  possible 
to  sj)eak  quite  definiti\ely  of  toxin  action  as  a  process  similar  to  enzyme 


.•Sr-wr^f   tmf* 


TOXINS  AND  ANTITOXINS 


157 


lox/iphorc  y/vup 


fo.rlii  )ni>l(ciilf 


action;  toxin  action  is  a  physical  property,  .icpcndcnt  upon  moloculur 
arrangement  and  shared  by  some,  at  least,  of  tlie  dissociation  products 
ot  the  cell. 

Toxin  action  is  the  first  essential  in  the  production  of  antitoxin. 
If  a  non-Jethal  dose  of  toxin  l)e  injected  into  an  animal,  it  disappears 
Ml  a  few  mmutes,  because  it  is  taken  up  by  the  cells  of  diHerent  organs 
and  by  the  leukocytes,  and  can  in  most  eases  be  recovered  from  the 
ur^ans.  And  here  is  the  crux  of  the  experiment.  If  tetanus  toxin, 
well  known  to  act  upon  the  nervous  system,  be  injected,  it  <lisappears 
:m(i  «in  be  recovered  from  all  the  organs,  except  the  nerwm  .susWm. 
I>nes  this  mean  that  the  nervous  system  has  none  of  iV  Quite  the 
.or.trary;  all  the  other  systems  give  it  up  readilv  because  their  cells 
have  not  entered  mto  a  hard  and  fast  combination  with  it,  whereas 
those  of  the  nervous  system 
have.     This   close    binding   or  Fia.  51 

anchoring  of  the  toxin  in  a 
tissue  is  the  condition  necessary 
to  the  production  of  the  anti- 
toxin, and  it  seems  to  be  the 
ca^e  that  the  tissues  that  bind 
tlf  toxins  closely  are  those  that 
dccelnp  the  antitoxins. 

It  is  not  necessary  for  the 
production  of  antitoxins  tiiat 
thf  toxins  produce  disease;  the 
toxin  may  by  heat  be  rendered 
liarniless  (toxoid),  and  yet  when 
iiijcetcd  can  cause  the  produc- 
tion of  antitoxin.  This  means 
that  there  are  in  a  toxin  mole- 
« ulc  at  least  two  parts,  one  of 
which  is  concerned  with  pro- 
'iiiriiig  the  toxic  effect.  If  this 
"xi'-  part  be  rendered  inert  by  heat,  of  what  .Iocs  the  remainder  of  the 
"1^  Mcule  consist,  and  what  does  it  do?  Since  such  a  modified  toxin  can 
-t  lip  immunity  it  is  clear  that  it  must  have  attained  close  union  with 
'I"  'cll  protoplasm;  therefore,  Ehrlich  concludes  that  there  is  a  part 
'■1  the  cell  devoted  to  the  function  of  fixing  the  toxin  molecule  to  the 
'-  n..  molecule  and  this  part  of  it  is  called  the  haptophore;  the  part  of 
thr  n.necule  which  is  actually  toxic  to  the  cell  bodv  when  fixed  to  it 
1^  ■  illed  the  toxophore.    This  is  represented  graphicallv  in  Kig.  ,-)l. 

1'  1-  evident  from  proof  that  we  need  not  here  giVc,  that  the  cells 

"■'    n  thus  become  combined  with  the  toxin  molecules  are  those  that 

!"'  i'l'c  the  antitoxin,  and  that  the  toxin  is  not  in  anv  sense  changed 

r    ""^l^f'\  \^  'tfY'^\*:"t  tliat  the  haptophore  of  the  toxin  molecule 

"     '11    I  !'i     [  ^1'     ^'T"  ">'"  ''•''  '*"^'"''  "thcrwi.e  it  could  fasten  upon 
■"'     '  II  ot  tlie  body,  and  this  power  it  obviously  does  not  possess.    There 


futptophune group 
receptor 


i:.s 


TiiK  Mni:niD  wn  rk.wtive  i-nncHssr.s 


must  In-  a  .l.'U'm-  ..f  rccrptivity  on  tin-  ].art  cf  the  coll.  A  s  lUutiiiK 
(•iiL'iiu'  iniv  liiivc  a  n.iipl.T,  hut  it  ciiMiiot  coiipli-  tn  a  car  unless  the 
car  also  lias  a  c.uplcr.  Klirlidi  lias  .Icvised  a  conception  ui  graphic 
terms  of  the  i,rocc».  If  we  >a.v  that  a  toxin  niolecnle  has  a  certain 
coniiler,  it  follow-  that  the  cell  mii>t  iiavc  one  to  lit  it;  l.ut  the  complex 
cell  has  to  provide  couplers  adapted  not  only  to  the  coiii.Ut  ot  the 
toxin  molecule,  hut  to  various  otluT  molecules  other  toxins,  iood- 
,,tuiVs  of  diil'crcnt  sorts,  and  so  on.  . 

These  adapted  c.Miiilers  of  the  cell  molecule,  a.lapted  to  many  dit- 
fcreiit  forms  of  couplers  on  fon'i,i;ii  molecules  lie  has  called  receptors,  or 
side-chains.  From  one's  chemical  study,  it  will  he  recalled  that  we 
depict  these  Mde-chains  as  reachin-  out  for  certain  suhstauces  to  satisfy 
them-  thev  are  unsatisfied  affinities.  To  go  hack  to  the  picture  «jt  the 
toxi-  molecule,  it  will  he  mcu  that  the  side-chain  is  reaching'  out  to 
sati'^fv  its  allinitv  for  the  Impfophorr  part  of  tin-  toxi.i  molecule,  that 
coupler  attracts  coupler.     It  does  not  matter  whether  there  he  a  toxo- 

Vu.   ,-,2 


1 V  .?-'.---;  •'',,>' 


F.hrlicli 
(i(  tlu'  tir 

(■nllipoun< 

I'li'iiifnis 


.t  ..r.l.  !■  (  > 
(,-i  of  til-  ■■ 


,„  ,,(  111, II  ni..livnli-.     Mol.-,  nil-  with  varic.iis  rc<-c-iit,.rr.  ,,r  li:i|.ti.i>li"r.>i 

i.lMptr.l  t..  .■..ii.l.m;iti.iii  witli  till'  h:i|)lii|>li"rc>ii^  i:n,ii|w  ^'•'  ..f  v.-iriniis 
I,  thilii       It   will  !"■  If.t''l  that  thiTi-  is  un  iiicili:illi-ln   l).v  which  Ihi-  liiv 

„„|„,.,i„K  .  :,„  i..-  ,lir..  tly  att:,.li,.,l  t..  the  c.ll.     iM.  r„rh,t,.l,  .tftrr  Khrli 


(•heinical 
.iphtiruiis 
h.) 


phore  part  of  the  molc.'ule  or  not;  the  toxojihore  jiart  of  the  molecule 
has  no  power  of  satisfyiiif;  the  side-chain,  ami  cannot  couple  with 
it;  hut  if  the  haptophorc  part  join  with  the  cell  the  toxophore  part  is 
hr'oujilit  into  direct  coimectioii  with  the  cell,  and  the  toxin  cun  thus 
hecome  part  of  the  (••■11;  in  other  words,  can  attack  it.  To  apply  this 
to  a  practical  case,  let  us  take  that  of  di])htlieria  antitoxin;  the  toxin 
molecule  fastens  on  a  cell  hy  its  liaptophore  iiart  and  its  toxophore 
part  acts  upon  the  dl;  as  a  consequence  the  cell  throws  out  many 
additional  side-chains,  antitoxin  molecules,  which  hecome  free  in  the 
blood;  the  toxin  molecules  pick  these  up,  couple-  with  them,  and  so  are 
satisfied  without  reaching  the  i-ell  at  all. 

There  is  a  normal  discharixe  into  the  hlood  plasma  of  a  larpe  number 
of  potential  antitoxins,  (piit.-  ai)art  from  the  stimulus  of  special  toxins, 
M)  that  OIK-  is  tempted  to  think  antitoxins  may  not  be  so  purely  si)eeili<; 
as  has  heeii  stated.  Khrlicli's  -  >i.k-ehaiii"  theorj-  supposes  that  ;i 
cell  once  stimulated  to  perform  a  certain  act  does  not  necessarily  cease 


>"<WftMf'S  v^-^ ' 


Tfti:  KIDK-CHMS   TIlF.oriY 


150 


■  loiiiKso  wlini  tliciiimicdiatc  iiccl  is  pjist,  hut  kf(|)S(.ii  prodnciii-r  tinTii 
(■(iMtiiiually  fVfii  alter  the  stiimiliis  lias  Ix-cri  rciiiovcil.    Tlic  toxiiriiiolc- 
ciiU'  stiiiuilati-s  the    dl  to  throw  out  mri)t()rs  like  the  rerrptor  whidi 
first  fix(-  it.     It  is  sii|)p(.s(.(|.  in  terms  of  the  theory,  that  these  fresh 
receptors  are  coiitimiallv  thrown  oil"  and  eonstitnte  tiie  antitoxin.    It  is 
eimvenient,  htit  dilHciilt.  to  understand  how  tliis  tliins,'  happens,  and 
at  this  point  .ve  propose  to  indicate  a  mollification  of  the  side-cliain 
tiieory  as  it  is  ordinarily  mider>tood.    .\s  we  hav,-  indicated  !)efore,  tlie 
lell  consists  of cytophism  and  nucleoplasm,  not  to  lay  stress  upon  the 
paraplasm.     When  a  toxin  l>i-comes  ahsorlied  into  the  cell,  we  do  not 
picture  it  so  nnich  as  fixed  to  the  hiophoric  molecule,  as  lyinj;  Ioos<> 
ill  the  cytoplasm  and  conihinin-;  with  tlie  side-chains  of  t!ie  hiophoric 
iiiuleculc,  dissociatin-;  them  from  the  molecule.     If  there  are  enough 
■t  such  toxii.  molecules,  the    l)iophoric  molecule  loses  side-chains  so 
rMi)idly  as  actually  to  he  destroyed,  "pulled   to   pieces."     This  docs 
not  mean  that  there  must  he  a  toxin  molecule  for  every  side-chain 
detached,  hut  rather  that  enzyme  action,  as  we  have  explained  it, 
nnist  play  a  part,  and  that  a  toxin  molecule,  having  detai'hed  a  side- 
chain  i.s  free  to  break  itself  away  from  it,  and  at  oik-c  fix  ui)on  and 
detach  a  new  side-chain  and  another  and  yet  another.    Only  upon  some 
Mich  assumption,  we  think,  is  it  i.ossiWe  to  explain  satisfactorilv  the 
•  uses  where  a  mimite  amount  of  toxin  can  kill  lar<;c  animals.'    ',Ve 
think  that  poisons,  other  than  toxins,  wreak  their  etl'ects  hv  a  sitijjle 
;ict  ()f  union  with  the  hiophoric  mass,  while  the  toxins  nnist  he  able  t(. 
.lit  like  fermeiiis,  with  a  rei)eatinf;  action.     If  we  were  to  supi)ose  that 
the  toxin  molecule  made  a  single  act  of  union  with  a  side-chain,  it  is 
li.ird  to  see  why  the  dissociation  of  a  sinjjle  side-chain  should  at  Once 
-iiise  the  hiophoric  mass  to  set  free  a  lar-je  munl.er  of  similar  sidc- 
<  iiMins;  hut  if  the  toxin  molecule  should  he  able  to  repeat  this  act  in 
'|iiiek  succession  again  and  ajrain  and  yet  ajiain,  we  can  imaj;ine  the 
'1 II  establishing  a  habit  in  the  production  of  the  new  side-chains.     It 
"ill  be  understood  that  this  implies  activity  of  a   lii<;h  order  in  the 
l'i"|)!ioric  molecule:  it  is  i)re(isely  this  activity  that  marks  the  resist- 
11-  cell  as  diti'ereut  from  tin   cell  against  which  the  toxic  attack  is  at 
'Mi.c  successful  in  causing  cell  death.     Let  us  dijrrcss  here  to  jrive  an 
iNainple:   instead   of  the  abstract   toxin   molecule,  ri'ad   tetanotoxin. 
iii-tead  of  the  bioi)lioric  molecule  consider  a  sinjrlc  cell  of  nerve  tissue: 
|h'  tetanotoxin  joins  with  the  receptor  for  it  and  detaches  it,  and  free- 
II-  itself  from  the  receptor  it  has  taken  nj),  there  betjins  a  race  between 
''•Mil  and  cell,  as  to  whether  the  cell  can  produce  more  receptors  than 


il, 


toxin  can  (htach;  if  it  can,  the  exci^s  of  them,  continuing;  to  be 

"wn  off,  constitutes  tetatio-aiititoxiii,  and  thus  a  relative  immunity 

Hii'  result  of  an  unsuccessful  toxin  attack,  just  as  the  soldiers  of  a 

"iiMin  become  more  efficient  by  reason  of  each  occasion  on  whicli  the 

ider  attemi)ts  but  fails  to  ca|)ture  their  stron-rhold.     It  will  lie  seen 

M  tlie  above  that  our  eoncejjtiim  of  inmnuiity  depends  u))on  the 

I  hovering,  so  to  say,  in  the  cytoplasm,  and  not  upon  it  being  part 


'  Tsawmmefwmesimw 


r-n.  53 


.Y. 


II  Tm 


„„1,„,  .ho  ell,  an.l  ,„,.s..,«nK  si.l.'-Wuuns  of  vun.ms  ;|  ^'  ^;  ;  ;    J     j  ^  V„„  „„.  ,„„  ,,j.  d„soc,.ti,.n 
.„U.-l„nn.-.  fro,,  n.ol..  ulcB  (X.  V)  .l,m,»..  .no  "-  'J,     .  '^^  „„,„;„„.,,  „„,„„y  of  ,h..  b.ophor,.. 

.,,  „„.r.  ..on.plox  n,ot,.,.,.l..,  also  ,,l..,rlH.,lK  ';;-''^;   ':;;;::;;:;;:':,„.,.  ,„„,„..,.  ,„.y  boco,n..  «.,M..l 
H..,l  aro  lM„lt  up  by  ..  .0  for,,,  tl,o  ^^'''^  '■;■'•;.  ^    ^.  ,„,in^,he  nght  or.U-r  of  h.ptopl.orous  ,ro„p- 

,.y  a..r..,  u„.  to  a  ..,l,.r  U 1''"")  ™'''  ■':.',"  fin  ,  „,ol-ul..a  of  .he  E  order  .„ay  not  n.erely 

i,,,,  U  i,  ,  onreivable  <hut  no,  .how,,  ,         '     ;•  '^         „  „'  '  ,  ^  ,,.„.„„,..„  ,„■«  i..  ,l,e  ey.oplas,,,.  or  .U»- 
,.,irfy  ,U-  M,l,.-,.h„in,  l.,.t  ,le.„.h  .    »o  .1..  .  .1-.  ';'"^;    ",,„,,„„,,  ^,,  .liflusinK  into  the  cytoplasm  hr, 

ehar.,.,,  f ,  .1 11  (-.iv  ''f '•"''f;;;,,;L;  tie      oZre   co.,;hme,  «i,h  ..  and  detaches  .. ;  h". 

„  Mr..„«er  Mflinily  for  the  ...l.-.-ha.n  .1  than  has  tf"^    '    I^  ,  ,  ,,,„,„u^.„„  l,ave  now  a 

.h,„  de,aeh..d  and  free  in  .he  ..to.^as.n  -  ,-  n^oul.^  ^    pr.^-.^  ^  _^^_  ,-    ,^,^,,^^^  ,__^  „ 

„,ronK.-r  a.lin.O   for  the  .1   .„o,e,y  of    he  '■3\,^,,  ,..,.,,  ,,f  Mi.,,c,.-ia,i.,^ 
„.„i,.,,  f-,  whnh  a.a,n  heeon...  f,ee  "'    ''V  '   '   f ,^    ,X  .'ell  ,..,n„la„„«  an.„ox„,.,  and  then  ,n  .he 

,,|,er.-d  sur.omehUKS  the  '■^" "-••"':;  •"^",.  ,,.    ^  ,„„,p„„nd,  and  no,  ,he  s,.ie-el,„u,  .1  atom-,  ..- 
w„h  the  .1  .,.o.e,>  iK.eo,„e  neutral,,  d,  ,t .»    h    '-  -i  ^  ^^^_  __^_,^_^,  ^,  ^^,,  ,.  „,„,.^.„„.,  ,„«  s,de. 

,„,„ii,„,e,  .he  ex.rae,  llular  ant,tox,n.    4.  ^^    '^J'^^  ^  ,„  .^e  biophore  or  free  ,n  the  cytopto,: 

,„„„,»  .4  l«>eon,e  .„nl.  „P  in  .er,e„  and  ''"   ;      V'^^^    ;;  "J,    „„,,„  Z..  .■ondi.,ons  will  bo  the  pro- 
.he  ,nore  ,h are  treed  l.y  .he  -""";;'_',   '^^.^'.^^^^  ,  „,„„ula,e.  .he  eell  .0  ,he  prclue : .;  ;■> 

■::t:i^::::::::^^2::^^  ;;;h:';:aU>.  .a.-eh..  era.  upo.  «h.eh  it  e«rta  .pec. 

a^'tion. 


mmmi'*^mT"mm.  ■  '^•-'^s.z^mws 


I'RKCIPITINS 


161 


.1'  tlichiophoric  mitlfciilc.  Our  u\va  of  antitoxin  prixlnction  is  expressed 
L:riiplii.all\  in  Fi^.  ■');!,  the  tliorouKli  >tii(ly  of  wliich  we  would  counsel. 
The  Mode  of  Union  of  Toxin  and  Antitoxin.  If  toxin  and  antitoxin 
lie  allowed  to  unite,  neitliir  i<  necessarily  altered  in  the  j)roeess,  because 
;it  least  one  of  tiieni  can  he  separated  uiiclianjied  from  the  mixture; 
liirtlier.  toxin  neutralized  by  antitoxin  may  be  neutral  for  animals  of 
one  species  ami  jjoisonous  for  those  of  juiother,  which  may  be  explained 
l>y  the  statement  that  there  are.  in  the  blood  of  the  second  animal, 
-ul.stances  with  so  strong  an  affinity  for  the  antitoxin  that  they  unite 
uith  it.  dctachins  it  from  the  toxin,  whiih  is  thus  left  free  to  act.  If 
toxin  and  antitoxin  be  allowed  in  vitro  to  iict  one  u\»m  the  other,  they 
Income  niore  closely  boond  one  to  the  other,  and  in  vim  the  lonpcr 
tlif  toxin  acts  in  the  cell  the  more  firmly  does  it  become  fixed  to  the 
nrcptors,  and  the  more  difficult  is  it  for  the  antitoxin  to  detach  it; 
thus  the  later  in  the  course  of  the  disease  the  antitoxin  is  injected,  the 
lt>s  chance  it  has  of  bein^  effective.  The  v<  r\  fact  that  antitoxins  can 
(liter  the  cell  and  arrest  the  infective  process  bears  out  the  supposition 
that  the  toxins  when  they  are  setting  up  eel!  disturbances  are  not  actu- 
;illy  fused  into  the  biophoric  molecule,  but  are  acting  upon  it  from  with- 
"iit.  that  is,  in  the  eytoi)lasm.  The  action  of  antitoxin  seems  to  be 
tliat:  (1)  it  neutralizes  free  toxins  in  circulation,  so  preventing  their 
111  tioii  upon  the  cells,  and  (2)  it  gains  entrance  to  the  cells  and  there 
(litaclies  toxin  molecules,  thereby  setting  up  the  excess  of  receptors 
ni((ssar\-,  as  well  as  neutralizing  the  toxin  molecules  temporarily 
S''t  free. 

Inst  as  enzymes  cause  the  development  of  anti-enzymes,  so  other 
'lillii-ible-cell  i)roducts,  particularly  proteins,  have  a  similar  power. 
Precipitins.— If  the  culture  fluid,  in  which  certain  germs  have  been 
L'ri.uii  and  from  which  they  have  been  remove<l,  be  injected  into  the 
;iiiiinal  body,  there  appears  a  substance— an  antibody— in  the  blood 
M  rum,  so  that  it,  addefl  to  the  original  culture  fluid,  causes  a  precipitate 
111  tlic  proteins  in  that  fluid.  These  antibodies  were  originally  called 
coagulins  and,  later,  precipitins.  This  power  is  possessed  not  only  by 
-Till-free  culture  fluids,  but  by  many  proteid  substances  of  animal  anil 
•-•table  origi;,,  such  as  milk,  egg  albumin,  horse  serum,  globulins 
tr'  in  bidod,  albuminous  urine,  pleural  exudate,  vegetable  proteins  such 
•I  "Itstin,  hordein,  etc.  The  action  of  these  is  remarkably  specific; 
1'"  ■  \ample,  if  human  blood  serum  b'  ,  octed  into  rabbits,  the  rabbits' 
Mr  nil  causes  a  precipitate  in  human  •  nm,  but  not  in  dogs'  or  goats' 
■^1  r;i!ii.  and  this  constitutes  a  valuable  ,,iedico-legal  mod<-  of  deciding 
iliiod  stain  be  caused  by  hiunan  or  l)y  other  blood.  But,  still  deal- 
ith  this  example,  although  the  treated  rabbits'  serum  might  not 
a  precipitation  in  dogs'  or  goats'  blood,  it  may  in  that  of  the 
I  or  the  orang,  because  of  the  relationship  that  exists  between 
nid  tliese  animals.  The  more  nearly  two  animals  are  related, 
nater  likelihood  is  there  that  the  proteid  substances  in  their 
ire  the  same,  or  similar,  and  that  they  will  give  rise  to  the  same 
!1 


if 


B    k   t\ 


^^^sf^-^^jgwm'  i^3^.M 


ir,2  THE  MORBID  .l.V/»  REACriVK  I'liOiKSSES 

..  .i„.ilar  antil....li..s  ..r  j.r...ipitins.  N.'v.rtl...l.s.  tl..-  i;-;i'i;;;t;- 
is  i....>t  mark.'.!  vvitl.  tl..-  I...in..l..^;..ns  s.-ruin.  tlu  t  i>.  tlu  -' run.  .  i  u 
':Z~  'finally  um-I  in  th.  .Mu-mnn.ts.  a>ul  ;;■"■.,!"">  J^^^^^ 
,  ,  ,  „..,.,  „,,t  tW  ...ost  M,ark...l  pr...  pjtatuH.  of  all  w      o.-nr  .nl>  the 

•'    .     it     ...t  i.rut.i,,.  i..  a  1.I..M.1  sm....  Lave  so....tl....K  ...  .•...........,, 

„„1  prrripit..i.l>  aM.l  ovn.  a..t.pn-np.t.,.s  ^^^^^.||. 

in   .  fSr^'li...  r     u-M  th.n-  is  a.l.k.l  to  that  ....-Ih.m  the  ser..n.  of 

t  t    ■     .    It     H.ws  .h.th.r  the  in.livi.l..al  atVon  1...^'  the  seru.n  has 

h.     .,  t     .r,.   i..reete.l    xvith  typhoi.l  ImciUi.      A,'^l..t..K,t...r>     ests 

'  i        .      ...otile  as  w d    as  xvith  ...otile  or};a...s..is,  a...l  are 

'r.  •::.; Uhi:     '  ' .^  tvphoi.l.  .lyse..tery.  t..l,erc..losis.  plague. 

:;    in  ,     nil  with   HaVilh-s  eoli.  ,>yoeya„ens.  pneun.oeo<.eus^ 

'      n    ,  o...  .s    a.ul   >ta,.hvlo..oee..s.     A,'^h.ti..atu...   .s   spec-.he   to  t 

xZ       1       wi  1.  rrlJrh,  hujh  'IHulion.  of  the  h,>...ol.,Kous  sen.....  tl 

^t    u    r  oruanis,..  <-o,..er,.e.l  is  the  o,.ly  o..e  to  show  <  '""P'^  j ' 
r    u.  io>,  .••...  l.e  ..l.serve.l   ii.uler  the  ...irn.seope  ..r  ...  In.lk    when   .. 
1  'si-  fo  n.ati.>,.  of  a  Hoee..h-..t  s...li..K-..t  is  see..;  hv.,jK  a... 
:::;;"  h;;::^  '1;..-  pro.lu..e.the  H.e,.o.e......  a...l  t  .  .....non  of  <^;.a 

,,„.illi  ,,,„ses  the   fonuatio..   ot   a««h.t......s       Ihe  powtr  <"   '»"•  ^^^ 

StinMio,,   ,..ay  re,..ai,.   i..   the   sen....   tor   a    hm.   t,...e   after  the 

'"We'e'niuori    uliat  a,,h.ti..i..s  are.  l„.t  we  k,.ow  that  they  are 

;:;^':;;t;::^::;.it;;;;;;th:'f;;;.tthatthe^^ 

i„    ...tal  1.1 1   or  in  the   tir>t    years  o.   eh.l.  hoo.l  p^<;^  w^ght  to 

n..;^?;  V  ev  i  H-  eriolvsi>.s  .bo.lies  that  ea.ise  the  .iestrt.,  t.oa  of  ba^ 

t'ri.;'  i^      rther  ^vi.l.ot  tl.at  o,.e  or,a..is.,i  ca,.  ,.ve  nse  to  m-  e 

;;    .m     :.^,h.ti,.h..  a...l  i..  the  .-ase  o.  l.aet.r.a  '  -''  an^  rektjjl^ - 

me  another  so..,e  of  these  agglutinins  are  the  ^ame.    ^\e  think,  there 


W^- 


A  aah  I  •  TI\I\S—C  YTOL  YSINS 


163 


I'cirr.  tlmt  M  s|Kci«s  of  organism  can  jrivi-  rise  on  tlic  one  hand  to  an 
luu'hifiniii  tliat  is  sjicciHi'  to  itM'If.  and  to  others  tliat  an-  also  capahh- 
>.l  l>«in>;  fomifd  U\  other  rehited  orjranisnis.  'I'hiis  lui<illns  f  ean  lead  to 
ilieproduetionof  acj^hitinins  A,  H,  (',  D.and  K,  whereas  l>a(ilhis  II  can 
Inrni  D,  K,  K,  (1,  and  FI,  and  >o  <.n.  'I'lie  nature  of  the  a>;>;liitination 
jirueess  is  prolmhiv  that  the  ajr^-'Intinins  lirin>;  idioiit  an  alteration  in 
I  Ik  inoh'cuhir  attraction  or  tension  l)et\vefn  tlie  liaeteria  and  the  finid 
imdinin.  W'v  woidd  correhite  witli  this  the  KatheririK  into  rouleaux  of 
tin  hlood  corpuscles,  and  the  jihysical  experiment  in  whicli  niutelies 
I.I  repr»'sent  hacilli)  or  disks  of  cork  (to  represent  red-hlood  cells)  are 
in.ited  with  hard  soap  :ind  floated  in  a  tub  or  water;  they  float  about 
ir.e  till  the  water  is  faintly  acidulated,  atid  then  they  gather  to^rcther 
into  clunii)s;  if  the  water  he  rendered  alkaline,  the  chunps  if  liroken  uj) 
iUiuiit  reform.  First,  there  is  |)roltahly  a  junction  between  the  agnlu- 
tiiiiiis  anil  the  l)acterial  cell,  an<l  as  a  coiise(|uence  a  i)hysical  clianjrr 
i~  urouKht  in  the  mcilium  in  wiiich  they  lie  and  in  the  surface  ten>ion 
il  I  lie  liaeteria,  a  change  with  which  the  ^nlts  are  concerned. 

Cytolysins.  The  blood  of  one  jmtsou  inject«(l  into  the  body  of 
iniother  may  lead  to  the  dissolution  of  corpuscles  of  the  latter  individual 
nr  tu  coagulation  in  his  vessels.  If  an  animal  .\  be  ino<ulatcd  rei»eate<lly 
"iih  small  amounts  of  the  l>lood  cor])Uscles  of  an  animal  H  of  another 
-|ii<  lis,  within  a  few  days  the  blood  .serum  of  A  gains  the  junver  of 
Inking"  the  blood  of  H.  that  is,  of  destroying  the  red-blood  cells  of  it 
uiili  lil)eration  of  the  hemoglobin.  The  injection  of  the  corpusoles 
Ii.mI.  to  the  formation  in  the  blood  of  A  of  a  cUoto.xin  or  cytoly.sin. 
U  111  II  this  was  discovered,  a  series  of  similar  lysins  were  determined, 
iiM  hiding  leukolysins,  which  arc  made  by  the  injection  of  leukocytes. 
iIm  Iriikolysin  being  specific  for  the  kind  of  leukocyte  introduced. 
Miiiiiarly,  nephrolyslns  and  hepatolysins  were  discovered,  able  to  set 
iip'lt generations  in  the  kidney  and  liver  cells  respectively;  in  fact. 
till  ((lis  of  every  organ  seem  to  have  their  specific  lysin  able  to  act 
t~|..(ially  upon  that  organ.  The  destructive  efl'ect  is  most  marked 
« 111  II  the  animals  used  are  of  widely  ditlerent  species,  in  which  case 
till  iy,ins  are  called  heterolysins,  but  there  is  some  interaction  even 
'"'urn  animals  of  the  same  species  (isolysins).  Hut  it  is  not  possible 
til  iiiMiiufactiire  exi)erimentally  autolysins,  that  is,  sul)stances  derived 
I  :m  animal  which  can  break  up  its  own  cells.  This  ob.servation 
1  keeping  with  the  impossibility  of  making  anti-enzymes  to  the 
iiion  enzymes  of  the  body.  Before  leaving  this  part  of  the  subject 
necessary  to  note  that  while  a  cytolysin  ads  most  powerfully  upon 
I  lis  of  the  special  kind  which  constituted  its  antigen,  and  in  reaction 
■icli  it  was  produced,  it  may  have  a  certain  lesser  efl'ect  upon  other 
iind  this  is  not  wonderful  when  we  consider  the  common  origin 
'  I  tils  of  the  body  and  the  likelilio(Ml  that  they  will,  therefore,  have 
ill  qualities  in  common.  Just  as  occurred  with  precipitins,  if  cytoly- 
■■'  rautiously  injeclfni  anti-cytolysins  can  be  obtained,  and  these 
1  iitralize  the  action  of  the  cvtolysins. 


Iri'i 
i>  I 

Cl.l! 

it  i- 
tli, 
ti.  . 
cci: 
(iff 


It  Ma.  awiiw  ]  :w^ats» 


164 


THE  MORBID  AND  REACTIVE  I'ROCKSSFS 


The  Mechanism  of  Cytolysis.  If  a  Kiiiii«»-l''>t  ''"^  raM.its'  ((.riHisdes 
iiijcctf«l  into  it.  its  stTuiii  (|iii(kly  Iktoiius  iictix.'  in  »»rcakni>;  up  the 
ral)l)its"  corpUMlcs,  uikI  is  tlun  <all.'.l  immune,  hut  if  w.-  iwiit  it  to 
7^:^"  or  m°  ('.  tl»-  la-inolvtic  action  is  arri'str.l,  aM<l  sucii  MTiun  is  sai.l 
to  l)f  inactivated.  If  sm'  mix  niM.it  '  .iirpiisfl.-  aial  li.atr.l  (inactivated) 
j;uin.ii-pin  smiin  iwliidi  cali^  f^rtl  lu.  lu-inol\  ms)  ami  a.l<l  to  it  tiormal 
piiiiea-pij:  or  ral.l.it  s.ruiii  1i.iim.Iv sis  (Kk-  tak«'  !•!  »'■  Tins  means 
that  heatini;  the  j;>iin<>a-pi^s  ^.rnni  has  .k-troyt-.i  Mun.tlnnK'  which 


tlic  normal  scrum  can  rc^tun    ^r 


that  til'  n    is  stuiicthinK  present  in 


Fio.  it 


unhcatc.l  inminnizc.l  piin.  ;i-i.i-  s.rnm  an<i  .i>;am  somcthmj;  in  normal 
sernm  that  is  necessary  to  l.cinol.N --is.  Tin  re  must  l.c  m..re  t.ian  one 
h(Mlv  im;-ent,  becnuw  non-inimnnc  Kninca-pijj  scrum  is  not  nhle  by 
itself  to  produce  the  elf.'ct.  //(  fvrrii  cm  uf  ,7//o///.v/.y  the  rxidence  and 
covihinrd  ariiun  nf  thcxv  two  fnchrx  rmi  he  .sli<nru.    The  substance  (ievel- 

opcd  in  the  scrum  of  the  immunized  ammal 
is  called  the  immune  body  or  th"  intermediate 
body  or  amboceptor;  and  the  bo<ly  present  in 

)■  the  normal   (and  in  active  immune  senmi) 

y  is  the  complement  or  ijexin.    Hotii  are  pics- 

-|  c-nt  in  the  cytolytic  serum,  and  in  fact  it  is 

II  bvvirtiu  of  their  i)resencc  that  the  serum 

1  is  cytolytic.     From  experiments  we  (leduce 

that  the  immune  bo.iy  can  attach  itself  to 
tlu-  cell,  but  cannot  disintegrate  it,  while  the 
disintegration  is  done  b>  the  complement 
acting  with  the  immune  body.  (Iraphically 
we  express  this  by  Fig.  :A,  in  which  it  will 
be  seen  that  the  immune  body  is  imagined 
as  cai)ablc  of  a  double  attachment,  hence 
the  name  amboceptor,'  to  complement  on 
the  one  hand  and  to  cell  on  the  other.  Nor 
must  it  be  thought  that  complement  and 
amboceptor  are  iiu  relv  theoretical  names,  for  each  has  a  dcHnite  exist- 
ence and  is  as  real  as  if  it  were  a  chemical  enclosed  m  a  bottle  and 
visible  to  the  eve.  Further,  in  the  interaction  of  complement,  ambo- 
ceptor and  cell  an  exact  amount  of  each  is  necessary  for  a  perfect 
reaction;  an  excess  or  la<-k  of  one  or  another  leads  to  an  imperfect 

reaction.  ^  i     j     1 1,. 

The  Existence  of  Different  Kinds  of  Amboceptors.-  If  a  goat  be  doul)l> 
immunized  to  both  guinca-i)ig>'  and  rabbit.,'  ml  corpuscles  and  this 
goats'  serum  be  used  upon  guinea-pigs'  corpuscles  until  no  further  heni()- 
lysis  can  be  obtained,  we  find  that  there  are  \et  amboceptors  in  it 
capable  of  hcinolvsing  rabbits'  corixisdcs;  the  goats'  serum  thus  cm- 
tains  two  distinct  sets  of  ambcKcptors,  and  many  other  such  experi- 
,„..,,to.  |e.<id  us  to  (1.  .!h'<-  that  then-  is  a  multiplicity  of  immune  bodies 
(or  amboceptors). 

'  Amho,  both;  caput,  I  seize. 


Oiml'inntiiiti  of  cell  n.  "n.lio- 
c  ptor  (i.  iinil  (•tiiiipltinini  e.  1 1" 
ntnlioripinr  nmy  unite  willi  'I..' 
cell,  liiit  I'V  ilwlf  ciniii'l  •■ifTcct 
it.  The  coinplcT]..  nt  CMiinol  unite 
Willi  the  cell  cxc.-i.l  Ihrouiih  the 
amhoceptnr,  having  m.  ■Inplntinn 
to  the  cell  ilireetiy. 


^^^WMHagBiife.^M»frjaCTBasaM<3WBB»y<»gaJ!wyMiMMiiaa»tXa^  < 


CYTOLYSIS-BACTERIOLYSINS 


1« 


Th«  Exiatmce  of  Different  Kinds  of  Receptors.  -It  follows  from  the 
lii^t  stiitfinoiit  tlmt  th»'  tdls  imist  hixw  iiiultii)It'  •'ruuplers"  or  rccei  -um, 
aii.l  whil,'  (iuli  wll  may  Imvf  a  larj,'*-  s.-rirs  of  these,  tin;  st-ri.s  is  n..t  an 
nl.htKul  ..K-  for  the  celis  of  (hirerciit  iiuHvitliials  of  the  same  sr)ecies; 
t'T  I  .•  .';  e,  if  we  inociihite  a  Koat  with  serum  from  aiiotlier  goat,  the 
venini  ohtaine.1  from  it.  will  ht-inolyse  the  corpiiMJes  of  some  but  ;iot 
nl'  all  K'uits.  We  may  express  this  Kraphicaily  h\  saving  tiiat  if  goats' 
c<.r|)useles  are  capable  of  having  a  full  stries  of  receptors,  a,  b,  c,  d,  e 
,1,  aii.l  we  use  for  experiment  a  goat  whose  cells  have  receptors'  a,'  b, 
aii.l  r,  Its  serum  will  come  to  contain  amhocej.tors  for  a,  b,  ami  c,  but 
not  lor  '/,  «•,  /.  If  this  serutn  with  a.iiboceptors  a,  b,  and  c,  come  in 
contact  with  goats'  cori)usc|,.s  jiossessing  receptors  o,  b,  anil  c,  it  will 
ii<-troy  them  wholly;  but  if  with  corpuscles  jfossessing  receptors  a 
an.l  r,  it  will  only  partially  destroy  them;  if  with  corpuscles  pojsessing 
n  <rptors  d,  e,  and  /,  it  will  have  no  edect  on  them. 

The  Existence  of  Different  Kinds  of  Complements.— Much  debate  has 
taken  place  upon  the  (piestion  whether  in  a  given  bl(M»|  different  com- 
l'!'!iieiits  exist,  and  without  reca|)itulating  the  lengthv  evidens.;  we 
iiiay  state  that  it  seems  likely  that  there  is  multiplicity  of  complements. 
\\f  may  say  ihnt  (here  is  in  every  normal  serum  a  .series  of  complement, 
:;i  !  again  that,  in  tlifftrnil  <inimals  there  exists  u  certain  number  of 
'■/'  >icnl  complemenUs,  identical  at  least  in  their  haptophore  (or  coupling^ 
I'lits,  although  the  to.xophore  (or  destructive)  part  may  be  different. 
Ii^t  as  was  the  case  with  the  t.ixin  molecule,  st)  the  comi)lement  may 

•  imagined  as  of  two  parts;  just  as  the  toxin  could  be  m.  'ified  to  a 
I  "id,  so  the  com|)lcmcnt  may  he  miRlihcd  to  a  complementc  1,  which 
"ill  >till  have  its  old  affinities  but  will  have  lost  its  evtolytic  powers- 
Mill,  such  altered  complement  can  join  with  the  iminnie  body  and 
rUr  toxophonc  or  cytolytic  part  being  jww.  rless,  no  d,  mage  to  the 
"II  results  but  other  and  active  comi)leinent  is  pre-  ented  from  joining. 

Lastly.  It  may  be  jwinted  out  that  the  amount  '>f  .implement  present 
I'  a  variable  quantity,  and  it  may  by  various  ex[)erimental  means  and 
"V  ,lis.ase  be  reduced,  or  may,  by  the  injection  of  substances  like  blood 
!'l.' ma  and  broth,  be  increased. 

BacteriolysinE,  As  inoculation  of  animal  cells  leads  to  the  produc- 
|i 'H  ut  bodies  causing  the  destruction  of  those  cells,  so  has  the  inocu- 
lation of  vegetable  cells,  bacilli  for  example,  a  like  result;  thus  to 
'''•'■nil  perlect  immunity  against  bacteria  which  dceelop  endotoxins  two 
'I'  '!iHt  processes   have  to  be  carried   out:     (1)  the  development  of 

■'  uriniysis  whereby  the  endotoxins  become  lilwrated,  and  (')  the 

1;  riMtioP  of  anti-  (en.h.j  toxins.    Nor  is  it  by  any  means  easv  to  attain 

two  nsults;  It  not  infrefiuently  happens  that  having  gained  the 

'i    •    a  dose  of  the  living  germs  will  <aiise  <leath  in  a  relativelv  short 

;       '1;  the  bacteriolytic  power  that  has  been  acfiuired,  destroving  the 

'•'•ria    liberates  rapidly  s.)  large  a  quantity  of  endotoxin  that  the 
-■■■  "il  <iie.  of  intoxication.    To  combat  such  an  endotoxin,  it  is  neces- 

•  to  employ  a  method  different  from  that  used  in  neutralizing  a 


wsmtm^:wjt*^bSr»nriBif-r'^ai^ .  iaJHe«£i^s;5nffSHK<fiiseiaMMH^Kar- 


166 


THE  MORBID  AND  REACTIVE  PROCESSES 


diffusible  toxin.  If,  for  example,  a  giiiiiea-i)ij,'  by  successive  injections 
of  one  of  certain  pathogenic  organisms  be  rendered  inmiuue.  and  what 
would  ordinarily  be  an  al)undantly  fatal  dose  of  that  organism  be 
injected  into  the  peritoneal  cavity,  it  will  be  seen  by  removing  peritoneal 
Huid  from  time  to  time  that  the  bacteria  are  undergoing  destruction, 
and  this  ajjart  from  the  process  of  phagocytosis;  the  bacteria  are  seen 
to  become  motionless,  lo  swell,  to  become  rounded  and  then  melt  away 
by  a  i)rocess  of  gradual  diminution,  like  a  grain  of  sugar  in  water  (Pfeifler's 
reaction).  What  is  hapiu-ning  is  that  the  iinnumization  of  the  animal 
has  produced  amboceptors  and  the  normal  serum  supplies  complement, 
and  the  bacteriolytic  effect  is  i)rodi.ced  upon  the  bacterial  body. 

The  ambocei)tors  and  complements  are  called  antibodies,  and  exist 
in  the  serum,  and  even  in  the  plasma  of  normal  aniui.ds,  although  not 
in  large  amounts;  inoculation  by  a  specific  germ  is  needed  to  call  forth 
amboceptors  abundantly;  the  ambocei)t()rs,  as  we  have  said,  are 
multiple,  as  appears  from  the  fact  that  an  aniinal  inmmnized  agains* 
cholera  and  typhoid  pro\ides  a  serum  that  will  destroy  cholera,  and 
subsequently  also  typhoid  organisms.  The  appearance  of  the  ambo- 
ceptors is  not  immediate,  but  occurs  after  the  lapse  of  several  days; 
once  there,  hovever,  they  may  exist  in  the  .-^erum  for  a  long  period,' 
even  for  more  than  a  year  in  some  cases,  and  when  they  disappear, 
a  relatively  sligiit  inoculation  of  the  si)ecihc  organism  suffices  to  pro- 
duce them  in  abundance.  They  can  be  j)roduced  b\  successive  inocula- 
tions of  the  living  or  by  larger  doses  of  the  killed  germs  and  in  this 
way  immunity  may  i)e  obtaine<l  against  cholera,  plague,  typhoid,  and 
streptococcus  infections. 

When  the  com|)lcm<'nts  come  under  consideration,  it  is  seen  that 
those  of  different  animals  arc  not  identical,  and,  therefore,  the  immune 
serum  of  one  animal  will  not  necessarily  jjrotect  another;  when  one 
adds  to  this  that  the  amount  of  complement  is  reduced  in  disease  we 
can  partly  understand  failures  to  innnunize,  and  can  foresee  that  mixed 
immune  sera  will  ha\ c  a  better  chance  of  iu-ing  efficient  than  the  immune 
serum  of  one  animal;  furtlu-r,  human  serum  is  most  likely  to  afford 
the  right  order  of  compleincnts  for  human  patients,  and  a  relatively 
small  amount  of  human  scrum  contains  enough  coniplement  for  a  large 
bulk  of  andu.ceptors. 

Diversion  and  Fixation  of  Complement.— Diversion  of  Complement.— 
\\c  have  already  called  attention  to  the  fact  that  for  proper  imnmniza- 
tion  there  niust  be  no  excess  of  either  amboceptor  or  complement.  If 
a  suspension  of  bacteria  be  made  in  a  normal  serum,  which  has  been 
found  to  contain  sufficient  coini)lement  to  cause  bacteriolysis  when  a 
known  imount  of  inactivated  serum  is  ad<led  (an  amount  containing 
say  X  amboceptors),  then  if  ten  times  this  amount  be  a«lded,  instead 
of  bacteriolysis  being  hastened,  it  may  be  wholly  arrested.  This  is 
explained  as  being  duv  to  "diversion  of  the  complement,"  and  it  is 
supi)osed  that  the  excess  of  unattached  and»ocei)tois  have  a  greater 
affinity  or  attraction  for  the  complement  molecules  than  have  those 


FIXATION  OF  COMPLEMENT  167 

ambocept„rs  that  have  iKvo.ne  ,.artially  satisfied  bv  attach    ent  to 

t.nnin:rcm,,rment        Vr    ""'■";«'  ""^""'r    Ruinea-pig  serum  con- 

iiilipilla 

irom  a  rabbit  wiucli  has  been  iniectcW  witli  tli„  ,   i  i 

i;i   iiK'sfi.in      Tf  *u-    I  ix         •     "^'^"  '"jK-itu  Willi  tlie  re«l  corpuscles 

MruMi  tested  is  negative,  containing  m,  antibodies. 


168 


THE  MORBID  AND  REACTIVE  PROCESSES 


i'i 


However,  more  delicate  reaction  can  be  obtained,  if  in  place  of 
Wassermann's  so-called  syphilis  antigen,  there  be  employed  the  alco- 
holic extract  of  a  normal  organ,  or  even  soluble  soaps,  lecithin,  or  bile 
salts.  Fixation  of  complement  there  certainly  is,  but  the  reaction  is 
not  precisely  of  tiu'  same  order  as  the  Hordet-CJengou  phenomenon. 
Syphilitic  blood  serum  is  lound  relatively  rich  in  globulins,  and  it  is 
the  combination  between  the^e  and  lipoids  that  binds  the  natural 
complement  of  the  guinea-pig's  blood  present  in  the  mi.xture. 

Anitnitl  Venoms  and  Antivenins. — An  extensive  study  of  snake 
poisons  has  led  to  the  conclusion  that  the  raw  poison  contains  several 
separate  toxins,  such  as  a  hemolysin,  a  neurotoxin,  a  nephrotoxin,  and 
so  on,  and  that  some  of  these  attack  thn  cells  directly,  while  others 
require  the  intermediation  of  a  complement;  this  complement  is  some- 
times present  in  the  blood  serum  and  sometimes  exists  in  the  cell  that  i? 
acted  upon,  in  which  case  it  is  known  as  an  endocomplement.  By  the 
repeated  injection  of  minute  quantities  of  venom  into  lower  animals, 
antitoxins — or  antiTenlns,  as  they  are  called,  can  be  obtained  for  dl 
the  animal  poisons;  the  best-known  forms  are  those  against  the  venoms 
of  the  cobra,  scorpion,  spider,  toad,  salamander,  and  eel. 

Opsonins. — The  opsonins  are  substances  in  the  blood  serum  which 
stimulate  phagocytosis.  If  opsonins  are  not  proent,  phagocytosis  of 
bacteria  by  leukocytes  occurs  only  to  a  slight  extent,  whereas  if  opsonins 
be  present,  it  occurs  very  Hbundantl\.  For  example,  if  a  person 
suffering  froii'.  chronic  fiirnn<ulosis  ()e  taken,  o.nd  his  leukocytes  re- 
moved by  c«iitrifngaliziiig  from  his  st-r'nn  in  which  they  show  little 
phagocytic  power,  and  added  to  the  serum  of  a  normal  person,  they 
take  up  bactrria  very  rapidly,  because  tlie  normal  person's  serum  con- 
tains that  abundance  of  Oj-sonins  in  which  the  patient's  serum  was 
lacking.  The  normal  person's  leukocytes  j)Iaced  in  the  patient's 
serum  show  scarcely  any  phrigocytic  activity,  so  the  activity  depends 
not  upon  the  leukocytes  but  upon  the  serum;  the  substances  upon  which 
this  depends  (opsonins)  are  not  readily  altered  by  heat,  and  become 
fixed  by  the  bacteria,  not  by  the  leukoeytes.  The  bacterial  body  is  in 
some  way  acted  ui)on  so  that  the  leukocytes  can  sub'«'((uentl>'  ingest 
it;  the  extent  of  this  action  can  be  gauged  by  noting  under  the  micro- 
scope the  average  number  of  hacteria  ingestiil  by  one  of  thirt\  or  forty 
leukocytes  observtd,  and  comparing  it  wilh  the  niiinbcr  i!igcsrc<l  by 
normal  lenko'^yte-  in  normal  stTuin.  Certain  precautions  are  necessary 
in  the  utilization  of  this  phenohicnoM.  (1)  Tlie  bacteria  nnist  be  in 
ar.  emulsion,  so  that  n.  ii\  i,h  •!  iiicrobcs  arc  scjiaratc  and  not  clustered. 
(2)  Tlie  eniiilsioii  nnist  not  lio  thick,  icst  l;ivCtcria,  overhiiig  but  not 
in  leuko(.vtes,  may  api)car  to  be  aiinally  contained.  (I!'  The  counter 
should  have  considirabic  crainini:  bei'orr  trusting  his  results.  (4) 
The  same  pipettes  shonl.l  oc  nsed  i'T  the  same  stage  of  the  procedure, 
so  as  to  insure  accuracy  of  nieasureinent. 

The  opsonins  are  considered  to  be  j)r()tectiveand  l)y  thdr  action  upon 
bacteria  art-  M-ed  up.  so  tliat  it  l)acteria  arc  added  to  a  serum  and  after 


.-JSST 


AGGRESSms  jgg 

one  in  normal  serum  and  sViS.  1      i  ;•       '  P'"°^«^'y  "•  a  common 

opsonins.     If  smTii^d''; 3  roTS%T^ 

Incoccus  aureus,  the  gonococcus  B  co  fnr  R  T  k        i    ^'  .°'  ^**P^y- 

i"to  an  indivi,lual  ll  opso,,  n^  are     i.r  ^ 

anK.„nt  (the  negative. pha^):X7hicM^^^^^^^^ 

"omena,  concluded  thfthe      iSivramournf    "''""  *?  ^''^  P''^" 
furnishes  an  indication  of  the  Sn«;  J  opsofuns  in  the  blood 

condiLi.    ExceHent  resu  s  have  k!?  'T''"^^™^?*  «"  the  patient's 

.i.e  value  of  thi  methj  11^^ toc^I™    ta.  t^"^"'"'^'^- 

-;n.l™cy  .0  en,pl„y  larger  amoun.:  onSiiW  ™ 'X  aXoTJ 

"  »tress  upon  the  technical  observation  of  the  index TS  „  '^ 

"'UZ'  of  reaction  as  they  are  observed  cUnioLuy  °  "'^ 

^  V,.t^.l  .ntib„,ic:;:SheTe  te'  £S  n'lS'-f^iin"  •?'"'"- 

-'1  the  bacteria  taken  out  bv/ceSuTh^.i  .ndthTT  ''  ''""^-^ 
•T-anisms  Icilled  bv  snnl!o-h/  ,'-'""«""''.'"&.  and  the  few  remaming 

•i'ii'l  has  no  toxic  effc-cfS'      t '  •'"■-  ''"^f 'P*'^'^''  *^«  f'^^u'tinR  clear 

f'"";^:^^  of  ^e.^lHK'fcet;:i  ;S^;h:^K^:^^^ 

;;•'  '-tl'."Kin  the  inflammatory  exudate  (aggressin    that  h«;  J,1    ^' 

•'"  ' '.-.: 'X'|-.„e'„p2„.»  :t^V£  S,.r  "'^"^''"'  •'^  '" 


f^^ 


170 


TllK  MOftlilD  .\\n  RKM'TIVE  I'liOCKSSES 


By  takiiij;  tlu-so  into  accoiiiit  wv  exi)Iain  tin-  wcll-knowii  jjlienonu'iion 
of  "exaltation  of  vinilciKr"  hy  jjassa^'c  tliroiitrli  a  siK-cossioii  of  animals. 
The  virulence  of  an  organism  does  not  (lepend  only  upon  the  production 
of  toxins;  increase  of  \  irulence  does  not  mean  increased  production  of 
ectotoxins,  for  a  filtered  culture  of  a  virulent  strain  (»f  cholera  or  anthrax 
does  not  produce  more  symptoms  than  does  that  from  an  attenuated 
strain;  hut  if  tlie  attenuated  liacilli  he  injected  tiiere  is  phaj^ocytosis, 
if  the  virulent,  none.  It  ai>pcars  as  if  the  virulent  ba'illi  excrete  or 
discharge  substances  which  are  not  toxins,  hut  which  ha\c  an  inhihitive 
or  "anti"  action  upon  the  body  cells,  substances  which  do  not  necessarily 
combine  with  the  body  ct'lls  to  destroy  them,  but  either  neutralize  the 
ojjsonins  or  directly  repel  the  body  cells,  the  repulsion  being  greater 
than  the  attr'ction  exerted  by  other  hactei.  d  substances. 

Anaphylaxis.  -Anai)hylaxis  or  allergy,  is  a  phenomenon  connected 
with  the  injurious  effect  that  is  occasionally  wrought  by  serum  tl  e 
so-calleil  "serum  sickness'  and  "scrum  death."  From  the  early  days 
of  the  employment  of  antidiphthcritic  serum,  there  have  been  occa- 
sionally reported  cases  of  death  following  suddenly  the  injection  of 
the  serum,  ("ollapse,  unconsciousness,  and  convulsions  have  occurred, 
death  ensuing  with  startling  suddenness.  Less  severe  symi)toni-.  the 
urticarial  rash,  with  or  without  sy>tcniic  symptoms  of  lack  of  vvell- 
being,  and  otlier  milder  manifestations  following  the  use  of  s»Tum, 
are  familiar  to  all.  These  untoward  elfects  are  produced  not  by  the 
toxins  or  antitoxins  but  by  the  scrum,  and  it  may  be  said,  by  the  way, 
that  the  risk  of  these  is  the  price  mankind  has  to  pay  for  the  blessings 
of  serum  ther.ijiy. 

Again  we  shall  illustrate  this  phenomenon  by  a  concrete  example. 
If  .')  c.c.  of  a  foreign  scnnn  he  injected  into  a  guinea-pig  there  are  no 
immediate  etfccts,  and  the  animal  l>ecomes  soon  inununized  to  that 
serum.  Hut,  if  instead  of  .">  c.c,  as  little  as  ,  „„'„„.,  <'•<••  he  given,  and 
twelve  da\s  later  a  second  injection  of  ')  c.c.  he  given,  the  guinea-pig 
will  almost  certainly  die,  and  that  i[nickly.  Instead  of  being  rendered 
itmnune,  the  opposite  result  has  been  obtained;  the  animal  has  been 
"sensitized,"  and  this  process  of  sensitizatitin  is  (UKii/lii/ldxh  in  contra- 
distinction to  I'roplu/laxi.i.  In  herbivorous  animals,  the  same  result 
can  l)e  uainiMl  by  feeding  with  the  serum,  and  tiic  blood  (tf  the  sensitizeil 
animal  ■  omes  to  contain  a  substance  which,  when  the  blood  is  injected 
into  other  animals,  sensitizes  them.  In  man  and  onniivorous  animals 
a  single  dose  sometimes  has  the  ctVcct  that  the  two  doses  ])()ssess  in 
hcrhi\orou-~  animals,  anil  thus  serum  death  may   K'cur. 

This  .-( nsitization  appears  at  first  to  be  oi)posed  to  our  general  icKiis 
of  iiniuunit>,  i)ut  we  have  attempted  to  sliow  that  it  is  not  necessaril} 
so.  As  >hitwn  by  Vaughan,  the  i)act(Tial  proteins  can  be  s|)lit  up  into 
a  j)oisn!ious  Hud  a  non-])oisiinous  ])ortion;  tlic  same  is  true  even  el 
egg  jibuinin.  ;Mid  its  poisonous  portion  kills  an  ex])eriincntal  anini;il 
ju>t  as  doc-  tiic  poison  of  a  i)athogenic  bacterium.  The  same  is  true, 
also,  of  niu^t  viiiitable  proteins.     One  may  sensitize  an  animal  with 


--^MS-^^ 


tTiK    > 


THEORIES  OF  IMMUNITY  m 

the  poisonous  portion,  or  with  whole  aihuniin.  but  not  with  the  nou- 
po|sonous  portion,  that  is.  th.  cell  .substance  has  affinitv  for  he  "  - 
I.o.sonous  part,  an.l  for.ns  an.l   discharges   receptors    s'uited     o   t  is 

o'wZr;^  IT-  i''"'  f ""!:'' ''' ';'''  ''""'■"'"  f-  '"-^-ti^"'.  t^ 

.rt    if  we    ,  ,•    r  IT"  '^'"''t  '"''  '"''^ituate.1  to  the  non-poisonous 
part,  If  ueniject  whole  c^k  albumin,  the  cells  with  their  excess  of 
reccj.tors  attract  the  non-poisonous  j.-rtion  of  the  serum  to  which  thev 
are  acnustomed  and  set  free  the  ,,o.-  ,.k,us  portion  in  the  circu  ition 
winch  acts  u,.on  the  nervous  system  a.ul  produces  .leath.    Tlu '  econ  1 
.  OM- n  ust  be  large  enough  to  supply  a  fatal  .lose  of  the  poisonous  pa 
.itt.T  .phttmg  up.    It  seems,  further,  that  the  poisonous  portion  has  a 
M>-ud  affnnty  for  certain  cells,  an.l  it  is  this  local,  rather  ?han  gen^l 
-non  that  explanis  the  anaphylactic  phenomena.     In  the  guiner-p.V 

or  example  as  shown  by  Auer,  the  fatal  result  is  due  to  direct   nfluJ.^e 
upon  the  plan,  muscle  fibres  of  the  f,roncin.  causing  a  spastic  cmtrat- 

.on  w.  h  arrested  respiration.    In  other  animals  als,>  it  is  plain  muscih  r 
i.   re>    hat  ai.i.eor  to  be  specially  implicated.     What  is  true  of  the  el' 

; ""';.'-  ^"•^:.«f  ^'-'  protein-containing  horse  serum,  wl  k-l     o     s  tl ! 

I'.i^is  ot  the  antitoxic  sera  of  commerce 

This  does  not  explain  ^^hy  a  small  dose  sensitizes  while  a  large  one 

.  ailed  the  dissociation  ot  ions;  if  a  minute  quantity  of  salt  be  put 

ntn  a    arge  quantity  of  water  it  is  <lis.sociated  into  its  Xa  and  its  C 

..  s,  uV-reas   it  a  large  ,,uantity  be  used  it  remains  as  an  Xa(  1   nole- 

u  e.    .Mnularh  ,  tlu-  minute  dose  of  protein  may  be  dissociate.l  int     ts 

"H..nous  arul  non-po,>onous  parts,  of  which  the  former  is  in  q    ,     ity 

to.,  nunnte  to  produce  any  s.Mnptoms.  and  the  cells  are  abl     o^'  ct 

-I.v  to  the  latter.     I    the  preliminary  dose  be  large,  the  dss  da  ion 

.  .Ks  „.,t  .,,,,.,    ,,1  ,„..  ,.,„,,.  ,,„,  ,,,,,.„„^.  arruston  e.l  to  the     he 

■  ..  e  n  mo|c,.wle;  the  poi.onous  action  is  thus  expen.le.l  upon  the 

t^m  V       n  .r  17    ?""""^  r  ^'^'''  ''  ''  '■'■'^^  '"  *h«  circulation 
It   n.i>  be  recallc.l  t  iat  m  our  chapter  upon  pre.lisposition  (n    117) 

TZT^T        r'  ''!■  *'"■  ^'""'""^^-  '-tween'certain  t;'  of 
•|l;->^.KTaM ,   ...tluna,   hay  tcver.   -.tc.  and    these  anaphylactic  phe- 


THIOWEB  OF  IMMUNITY 

!■  N erynnc.  who  is  in  the  slightest  degree  familiar  with  mclical  litera- 

;      •  >  eM.lent  that  we  can  give  as  bri.-Hy  as  possible  not  an 

<  •    "        t    he  various  arguments  in  favor  of  ^  arions  theories,  but 

'!>    .1   very   i)n<-t   explanation   of  a   sinde  nractieal  ,„>..      VV      in 

''^-  l'"ve  seen  that  all  the  substances  that  can  induce  the  prcxluction 


172 


THE  MORBID  AND  REACTIVE  PROCESSES 


of  antibodies  (i.  e.,  all  antigens)  are  either  ceils  or  the  products  of  cell 
activity,  and  that  the  antibodies,  too,  are  the  prwhicts  of  cell  activity, 
and  that  one  group  is  a  kind  of  lookinR-glass  reflection  of  the  other. 
If  we  were  bacteria  we  would  regard  the  antibodies  as  toxins,  and 
our  own  toxins  as  protective  antibodies.  Two  living  organisms,  the 
animal  and  the  microbe,  are  pitted  against  each  other,  ami  the  increase 
of  virulence  of  the  latter  may  be  the  result  of  its  developing  anti-anti- 
toxins (which,  from  the  microbe's  point  of  view,  are  simple  antitoxins), 
corresponding  to  the  development  of  antitoxins  by  the  animal  and  tend- 
ing to  neutralize  them.  The  problems  of  immunity  narrow  themselves 
down  to  special  problems  bearing  upon  the  assimilation  or  digestion 
of  unusual  or  foreign  proteid  matter,  the  products  of  cell  metabolism. 
We  have  given  the  basis  of  Ehrlich's  theory  referring  to  simple  toxins, 
but  when  we  reach  the  cytoljsins  we  are  met  by  a  new  phenomenon 
in  which  there  is  not  simple  union  of  the  molecule  of  the  cell  and  the 
toxin  or  the  complement,  but  wiiere  tliis  is  brought  about  by  the 
intervention  of  an  intermediate  body  or  amboceptor.  We  may  here 
recapitulate  the  various  forms  of  antigens  and  antibodies  with  which  we 
have  dealt : — 


Eniymes 

Fhytotoxilw 

Bacterial  ectotuxin!) 

n    ^  -     /animal 
Proteins',  .  , 

(vegetable 

Bacterial  proteins  ('!) 

Bacterial  aggrfaains  (.?) 

Animal  venoms  Csimilej 

.\niniul  venoms  (cotiiplei,  ri'quirin^ 
interiiiediatiun  of  conipleiuent  foi 
action) 

Vegetable  cells  ^bacteria)  . 
Animal  cells  of  various  orders 


.leailinic  to  the  proiluction  of  Anlienjynies 

"  Ami  (phyto)  toiin. 

Antitoxins 

Precipitins 

Agglutinins 

Opsonins 

Antivenins 

I  ..  Antihcmolysins, 

(  etc. 

Baeteriolysins 
C'ytoIyHius 
Uemolysins 
Leukotiixins 
HepatrljHins,  etc. 


.\cting  singly. 


Ucquiring   in* 
teraction    of 

1  amboceptor 
(specific), 

2  complement 
Cnou.*I)ecific) 

Reviewing  this  table,  one  notes  that  there  is  a  progression  from  a 
simple  structure  of  the  absorbed  body  to  a  very  complex  one.  Accord- 
ing to  the  nature  of  the  body  to  be  absorbed,  the  binding  apparatus 
must  differ.  To  tie  a  simple  substance  to  the  biophoric  molecule  we 
may  presume  that  a  single,  simple  side-chain  is  enough.  When,  how- 
ever, we  come  to  the  giant  molecule  of  a  protein,  this  will  not  be  enough. 
Giant  molecules,  as  such,  are  useless  for  the  cell,  and  must  be  broken 
up,  dissociated,  by  fermentative  processes.  This  could  be  if  the  "seiz- 
ing arm"  were  of  a  nature  complex  enough  to  seize  the  molecule  and 
to  bring  into  contact  with  it  the  requisite  ferment;  to  borrow  an  example 
from  the  vegetable  world,  the  tentacles  of  the  Drosera  seize  the  object, 
and  cover  it  with  a  juice  that  is  digestive.  Such  a  complex  side-chain 
we  can  predicate  in  the  case  where  the  body  to  be  "lysed"  consists  of 


!S»riB' a*?J*tdia 


THEORIES  OF  IMMUNITY  173 

in  cells.  If  there  be  such  a  complex  siMen^hain,  the  nrwess  of  imnni- 
mzation  will  cause  a  repro<luction  of  such  sid^-chains  and  the  sS^ 
Cham  with  Its  complexities  will  be  elaborated  and  cast  off  as  a  comp  ett 
whole— as  an  unmune  body  t-o«ipieie 

su!!?^set'th^The°re'r  °' ^•''•P*^-^^''^^''"^  "P  '^'  >dea.  Ehrlich 
sLpioses  that  there  are  three  orders  of  receptors  for  food  nr  tnvJn 

molecules     (1)  The  simple  toxin  (/.  b)  is  anchor  Jby  a  re^pt^   Ta) 

of  the  first  order,  that  receptor  being  a  side-chain  with  a  haptophore 

ro  which  the  toxm  molecule  becomes  coupled  by  its  haXphore  c 

(->    For  protem  molecules,  a  different  order  must  be  imagined     The 

sule-cham  must  have  an  arm  for  seizing  (//,  .)  and  one\Td){oT 

Fia.  55 


The  three  order,  of  «de-ch«in«,  according  to  EhrUoh. 

tLlT  is'"a  hantoT'"*  ^J  ^^"'^  '^'  °^°'^^"'«  "^"^^  ^e  dissociated. 
\t  li,^  ^Ptoph^re  and  a  zymophore  (or  ferment-carrying  portion) 

re  ^  thlT'^^T  ''  ^^"""'^  '"  ^'^-  ^^'  "'  '"  ^hich  e  is^the  hapti 

r  tlvL??'"'''""'  ^l'^''  ^'  "«"P""S  ^'^^'  the  zymophore 
I  c    t.)  exert  its  ferment  effect  upon  thebody  seized.    It  wiU  be  seLn 

:Z  T^ri^'t  '"^%'''  \'  '^  ''''  «>""*-P-*  "f  the  attached 
„  ,  *  "* ,  F-  ^•''  {^-  ,  (•^)  ^'or  the  yet  more  complicated  case  of  an 
<  -t  o„  between  the  biophoric  molecule  and  a  foreign  Sll  we  must 
"•>  M.pp  ,se  a  complex  receptor  as  in  Fig.  55,  ///.  The  receotor  Z,f 
;;;;;.pa.leo  attaching  the  cell  to  be  acteci  upon  (^IdZZ^Z 
'  >it  /),  the  complement  is  figured  as  possessing  a  haptophoric  Dart 
'  .  ar.d  a  zymophoric  part  (.),  which  latter  corresponds  to  th"tox2 


171 


THE  MOlUilD  .\.\n  RE.iCTIVE  PROCESSES 


I 


plmric  pnrt  of  tlie  toxin  iiiuU-ciiK-.  When  fM>th  these  are  fixe<l  to  the 
original  (rll,  the  coinnnniiciition  Ixtween  the  zymophoric  part  and 
th<-  two  cells  permits  the  enzyme  iution  upon  the  attiielied  cell  (f)  to 
Ixflin.  When  the  cell  reee|>tors  are  produced  in  excess  and  diseharg'd, 
they  have  the  same  i)o\vers  of  attachment  as  when  fixcfi  to  the  hio- 
phorie  molecule  and  when  free  are  termed  hy  Khrlich  haptines.  Ilap- 
tines  are  thus  of  three  orders,  those  with  a  single  hapt()i)hore,  such 
as  antitoxins  and  anti-t-nzynies;  those  with  a  haptophore  and  a  zymo- 
phore ^rouj),  the  ajrj;lutinins  and  the  jm-cipitins,  and  lastly,  those 
with  two  haptophorcs,  which  are  the  amboceptors  rir  immune  bodies 
proper,  and  constitute  tiic  cytolysins  and  baeteriolysins. 

There  is  a  word  of  warning  to  be  ^iven  to  the  l)egiiir.er  in  intor- 
I)retinK  the  diagrams  which  we  have  reproduced.  We  are  not  sure 
that  the  toxin  molecule  becomes  anchored  on  to  the  biophoric  molecule 
and  .-.o  I)ecomcs  a  part  of  it.  The  interaction  of  toxin  on  haptine  is 
direct-  the  toxin  acts  upon  the  biophoric  molecule  in  a  way  that  is 
less  direct;  we  difft-r  from  Khrlich  in  not  regardin>r  it  as  becoming 
lirmly  attached  to  the  biophoric  molecule,  but  as  dissociating,  by  its 
affi'iity,  tiie  receptor,  the  toxin  and  iecej)tor  liecoming  temporarily  a 
free  unit,  and  imapne  that  there!)/  the  condition  of  unsatisfaetion,  in 
which  the  biophoric  molecule  is  left,  leads  to  the  formation  of  a  new 
side-chain  or  rece-)tor. 

When  we  cnsider  the  processes  by  which  bacteria  are  destroyed, 
and  their  cell  products  neutralized  we  realize  that  these  are  but  special 
exaniples  of  assimilation  and  digestion.  The  process  by  which  an 
ingested  microbe  is  dissolved  in  the  vacuole  of  the  leukocyte,  or  .t  bac- 
terium melted  in  the  body  fluids  is  probably  brought  about  by  a  pro- 
cedure of  i'.'.t  same  order  as  when  fibrin  is  digested  in  the  gastric  juice.' 
In  .10  Pl.t  of  the  whole  subject  can  we  neglect  the  importance  of  enzyme 
action  \Ve  readily  admit  nay.  we  citt^the  different  grades  of 
ej!.-.\  ;i;e  action  with  which  we  art  familiar;  how  ptyalin  acts  directly 
on  -larci),  and  enterokinase  requires  the  mediation  of  trypsinogen. 
We  think,  in  short,  that  toxins  and  cytolysins  are  of  enzyme  nature. 
Indicating  the  ^inilarity  between  toxins  and  onzymes,  we  have  anti- 
toxins and  anti-cnzynics,  we  have  natural  and  cxi)erimentally  acquired 
.•inti-enz,\  incs  just  as  we  have  actual  and  exi)erimentally  acquired  anti- 
toxins, we  h  ive  evidence  tlial  ii  minimal  amo\mt  of  enzyme  may  convert 
a  maximum  amount  of  the  substance  acted  on,  and  a  minimal  amount 
of  toxin  cause  dissociation  of  the  cell  substance,  even  unto  death,  or 
that,  umicr  favorable  circumstance;,  either  process  may  be  arrested; 
we  see,  too,  that  the  action  of  both  is  arrested  by  the  products  of 
•  lissodation:  both  work  with  chemical  exactitude,  so  much  enzyme 
nentraiizes  ^o  much  anti-enzyme,  and  so  much  toxin  so  much  antito.xin. 

'  Or  prrhaps.  inon'  ■((•ciiiately,  in  the  piinoroatic  juice,  for  such  digestion  is  lytic 
;iin]  w  now  rcconiuzi!  that  for  the  activation  of  tiie  trypsinogen  a  second  body  is 
ncri  ^^al■v.  'i  ryp>ini)(jen  is  inert  save  in  the  presennc  of  enterokinase,  which  may  be 
regarded  as  the  complement,  the  trj  pteinogen  as  amboceptor. 


mmmmma^mm 


-  -  .^^^  a.-  - 


-i:<*.:Sfc^t.i4fer;^- 


THEORIES  OF  IMMVSITY 


175 


Ue  <lo  not  know  tlic  stnictiin-  of  enzymes  or  r>f  toxin.s,  an.i  we  must 
tlierefore   express  the  process  l,y  symF)oIs  i.s  Klirlieh  has  done.     If  we 
iire  speaknig  of  enzymes,  tlie  enzyme  molecule  (eorrespon.lii.j:  to  the 

toxm  mo  eeule  of  onr  previous  illustrati.-ns)  has  a  haptophoric  (conph'nc) 
part,  and  a  zynioplioric  part,  and  inst.-ad  of  the  cell  IkmK  we  have  this 
tun.-   the  substance  to  1h   ferment.«d  (th.-   fernientesciMe  sul.stance) 
.Now  let  us  digress  to  the  consideration  of  tlu-  chemistrv  of  fernunta- 
tron;  lor  example,  dextrose  gives  rise  to  glucose  thus: 

C„H,,<)„+  E  +  Iti)  -   (;ir,,«»e  .  (•Jf,,()e+  E. 

()n«-  molecule  of  dextrose  +  11,0  =  two  molecules  of  ghuose.  In  the 
pre-^ence  ol  enzyme  (El  hydrolysis  octurs. 

The  moh-cule  of  dexfose  cann..t  he  split  into  two  equal  i)arts,  but 
'li\  ides  lui  iqually,  thus; 

^''="^""  =  {c:h::I]: 

Ijiid  the  hydrolysis  gives  i.w  a  fn-e  basic  IK)  ion.  and  a  free  aci.i  II  ion 
I  Ik  next  step  is  that  we  expand  our  last  fornuila  thus: 

The  dextrose  molecule  splits  into  two  parts,  one  of  which  has  positive, 
'lie  other  negative  affinities,  aiul  when  these  are  separated  one  attra.'ts 
■^  I'aMc  ion,  the  other  an  acid  ion.  Our  conception  is  that  the  enzMue 
"IiK'h  thus  splits  up  the  molecule  into  a  basic  and  an  acid  part,  must 
itMlt  he  acK  or  basic;  thus,  if  aoi.l  it  detach.-s  the  basic  complex  C'JI„0,. 
I.nt  the  hydrolysis  has  1,-ft  free  an  II  ion,  which  now  exerts  a  great*-r 
^ittraction  h.r  the  ('ellnO,  than  does  the  cizyme;  the  two  -..mbine 
aiHl  the  enzyme  is  set  free  to  break  up  anoth.-r  molecule  of  th.  de.tro.e' 
\\c  have  indicate<l  this  graphically  in  I'ig.  .-,(;,  the  term  r.cipi<nt 
n'lx'atmg  the  substance  (in  this  ,-xani,.le  d)  which  has  aHinitv  for  the 
iToken-od  molecule,  great,  r  than  has  the  f.Tinent. 

In  more  complicated  enzyni,    a.tion  such  as  occurs  in  the  i.rotein- 

i'littmg  .hgestion  ot  tryi.sin,  the  enzyme  is  a  compound  of  kinas.  un.l 

"•y|.sinogei.;  the  latUT  has  a  suitable  haptophore  groui.,  but  its  zvmo- 

n  M.re  group  is  unable  by  itself  to  sf.lit  the  protein  molecule  an<I  requires 

'iK'  assi>taneeot  the  kinaf^e. 

\yhen  we  liken  the  a.tion  of  enzyme  to  that  of  toxin,  we  recognize 
"a    then,  is  a  frecpient  sonn..  of  r-onf.ision  in  the  conception  on  the 
:'.i  t  ..th,.  worker  that  enzyme  aeti-n  results  ordinarily  in  the  produc- 
'">'  nt   substances  which  are  certainly  not  anti-enzvines,  and  there 
"IH-.rs  at  hrst  sight  to  be  n.,  similar  action  o,.  the  part  of  toxin  mole- 
■     •■>■     these,  we  are  apt  to  imagine,  pn-h.r    ..nly  antitoxins.    This 
I    ««^.•^    IS  a  mistaken  i.l.-a.     The  process  .,f  juncti..,,  betwe>en  toxin 
■•  "I  antit..xin  is  associative  an.l  self-limiting.  .....1  there  is  an  identical 

"-.ss  occurring  between  enzyme  and  anti-enzyme.     What  we  wish 


176 


THE  MORBID  AND  REACTIVE  PROCESSES 


espwially  to  point  out  is  that,  ci -rrespondinR  to  the  process  inanifest- 
iiif;  itself  In-tween  ferment  and  f(  iientesoible  si  l.stnnfc  which  is  <Jis- 
sooiative  and  rcnirrent,  there  is,  we  hold,  an  exactly  parallel  dissocijitive 


Fin.  M 


Simple  cniyme  action:  F,  the  eniyme  molecule,  hu  affinity  for  and  detarhea  A,  a  aide-chain  of  a 
protein  molecule,  forming  a  temporary  combination  with  it.  When  A-F  is  free  the  recipient  G  han 
a  itreater  affinity  for  the  aide-chain  moiety  A-F  knd  combine*  with  it,  the  eoiynie  molecule  F  becum- 
in^  lietacbed  and  rbady  to  dicaoeiate  a  aecond  aimilar  aide-chain. 


Fio.  S7 


Schema  of  toxin-antitoxin  actic  o:  O-A  (the  eide-chniu  .1  riinhiDcd  with  the  reiipient  G,  as  in 
Fig.  56,  wheu  iIischarKO.l  inm;  tic  rrll  into  i'lo  ".irroundinjx  fluid  is  an  antitoxtu  luoiecnle,  is 
dissociated  \>y  tiie  eniym*'  or  tcxiii  iiM.ieculc  F  ^^hiell  thus  joiniiiK  with  .1  lieconii--*  ip-utralt^rd. 

and  recurrent  proc«'ss  t)ccurrinj.'  b<  t^een  the  toxin  and  tlie  biophoric 
molecule.    The  one  essential  '!ifft,roi(  e  is  thut  the  enzyme  may  mani- 


■PI 


SYNCOPE,  SHOCK,  AND  COLLAPSE 


177 


f.st  this  .li>s«ciative  acti\ ity  ouUide  the  cell,  the  toxin  tan  manifest 
u  only  within  the  •  v\\  and  in  asscH-iation  with  livinjj  niattcr. 

It  is  when  th«-  enzyme  acts  u|M>ti  the  living  cell  that  anti-enzymes 
iirr  iir.Hhitr.l,  just  as  antitoxins  are  «levelniH',l  untier  lii^e  circumstances. 
AikI  ti.  explain  the  reliitionship  Jn'tween  the  fcrmentescihle  or  disso- 
riative  anil  the  antilnMly  or  ociative  activities  of  both  onlers  of 
>iil)stitnces,  we  siiK);ist  an  addition  to  Professor  Ehrlieh's  conception 
>'\  'I'll  Imin  acti\  itics.  In  toxins  ami  nntilxMlies  he  takes  no  note  of 
I  he  ^croup  of  junction  with  the  hiophoric  moh-cule;  when  (lisstK-iatefl, 
tlirriMnust  he  here  in  the  suic-chain  coni|»h'x  (which  in  our  diagram, 
Vh.  :.7,  is  Ni.lid  black)  a  satisfiable  affinity.  If  now  we  picture  the  toxiii 
nii.h'(iil( ,  nut  as  becoming  attached  to  the  biophoric  molecule  by  one 
of  the  sidc-chiiins  of  the  same,  but  fu  detachhvj  the  nide-chnin,  we  can 
solve  the  difficulty;  that  is,  we  can  regard  the  toxin  as  acting  like  an 
.nzyme,  «letaching  the  side-chain,  giving  it  up  to  the  stronger  affinity 
of  the  recipient  6'.  and  being  free  to  detach  another  side-chain.  Thia 
siilc-ckniu  phis  recipient  in  the  antitoxin  (Fig.  ')7). 

Ill  the  cell  this  antitoxin  cannot  act  because  the  toxin  has  affinities 
for  the  similar  side-chains  of  the  biophoric  molecule  still  adherent, 
unless  the  point  is  reached  at  which  wpiilibrium  occurs  by  the  accumula- 
tion of  the  products  of  the  enzyme  action  and  by  the  overproduction 
;md  discharge  of  side-chains  of  tli  particular  order  into  the  paraplasm. 
Hut  when  the  excess  of  side-cliain.s  j)lus  recipient  is  discharged  into 
I  lie  blood  stream,  then  circulating  toxins,  not  having  the  greater 
attraction  of  the  intracellular  molecules,  are  free  to  join  them  and  he 
iKiitralized. 

In  this  consideration  of  the  subject,  we  have  calletl  in  no  external 
lactor  save  the  "recipient,"  some  simple  but  active  ion  present  in  all 
-nliitions  in  which  the  enzyme  or  toxin  is  able  to  act. 


37NC0PE,  SHOCK,  AND  COLLAPSE 

Syncope  or  fainting  is  the  state  in  which  the  face  suddenly  becomes 
ched,  the  pulse  small,  rapid,  and  at  times  imperceptible;  a  brief 


•  'ill    n  I  If!  I 

uiiMincss  or  a  moment  of  mental  helplessness,  is  followed  by  unconscious- 
ness, the  iridividual  falling  "as  a  sail  falls  the  mast  being  broken." 
Tins  arises  in  various  ways:  by  the  sudden  assuming  of  the  erect  from 
I  lie  supine  position,  by  the  emptying  of  a  full  bladder  (with  probably  a 
"'  ehaiiical  fillin;,  of  abdominal  vessels),  or  by  strong  stimulation  of 
iisory  nerves,  in  other  words,  pain.     Unconsciousness  is  usually  brief. 
\-ain,  syncope  may  be  purely  of  emotional  origin;  many  medical 
iMileiits  will  re<all  cases  of  syncope  occurring  among  their  own  number 
ii'  -i.U'ht  of  Some  operation,  especially  if  the  surgical  procedure  be  one 
il:  at  is  undertaken  witiioit  an  anesthetic;  the  ready  mind  of  the  sympa- 
tiirtic  one  attriLuUs  t<>  himself  all  the  sensations  (and  more)  under- 
i:  ne  by  the  patient.    Personal  memory  recalls  vividly  a  football  match, 
\Mili  the  scattered  faMing,  like  pole-axoJ  siters,  of  nearly  half  a  score 
12 


■Miii 


MICROCOPY   RESOIUTION   TEST   CHART 

lANSI  and  ISO  TEST  CHART  No    2l 


1.0 


I.I 


1.25 


;-  iiiiiM 

i2  IK 


1.4 


IIIIM 

I  2.2 

12.0 

1.8 
1.6 


_^  x^JPPLIED^  IM/IGE     In 

^^i  ■♦■■':..!   l2i[   V-j.n   Street 

Hy-S  ^icnester,    New    ''ort.         14609        uSA 

*■=  ''6)    *82    -  0300  -  Phone 

^^  ''6)   288  -  ^989  -  fa- 


178  TIIK  MORBID  ASD  REACTIVE  PROCESSES 

of  undcr-ra.luatf  ..nl....ktTs.  .•..nsc(,iKUt  iiiu.n  tlie  loud,  sharp  snap  of 
al  L'boue  ofciu- of  the  i)lay<Ts.  .         , 

Shock  and  Collapse  ar(M.l.vi..iisl,v  iiu.ro  sovt-n-  con.htions.  lMr>t  there 
is  the  einoti...ial  shock  that  may  pr<..lu.r  .l.ath.  iho  case  is  cite.l  ot  a 
mock  trial  con.h.ctc.l  l,v  son,.-  stn<h'..ts  of  a  Scottish  T  n.vcrsity  upon 
an  ol.noxious  janit<.r;  In-  was  h-.l  to  th..  hlock.  >tn.ck  on  the  neck  with  a 
^vet  towc'.  and  picked  up  .h.a.k  In  less  extrenu-  ..ases  recovery  may 
take  davs  or  weeks,  instead  of  minutes  as  m  syncope.  1  her.-  is  hlanch- 
ini:  with  a  w.-ak.  feel.k-  pulse;  the  eyes  l..'come  sunken  th.  jheek  l.ones 
pnm.inent;  the  muscles  are  lax;  the  l.reathinf:  ,s  irre-ular,  the  tempera- 
ture lowere.1.  lletehin^-  an.l  voinitiuf;  ar.-  tre<inent;  the  ,.atient  lies 
limp  and  regardless  of  his  surroundings,  l.ut  not  uncon-cnis;  upon 
heiii"  aroused,  the  answers  -iven  hy  the  patient  may  he  slow  as  it  brought 
fronra  distance,  .liiiicnit  to  obtain,  but  they  are  rational;  voitiou  is 
laruelv  abolished  an<l  tluTc  is  extreme  general  depression  ot  all  l)odily 
function      Shock  ami  collapse  occur  in  the  foHowing  circumstances: 

1     \fter  onnaiion,  or  w..unds  associated   with   injuries  to  nerves 
These  mav  be  {a)  perii.heral,  in  which  the  terminations  are  atlected 
as  in  the  shock  after  burns,  after  a  shari)  blow  upon  the  testicle,  expo- 
sure or  irritation  of  the  peritoneum,  or  of  the  periosteum;  (b)  m  con- 
tinuitv,  as  after  sexcrance  of  a  largi^  nerve  such  as  the  sciatic;  (c)_ centra 
as  after  operations  upon  or  removal  of  brain  substamr.     1  am  in  all 
these  is  not  an  essential;  shock  may  occur  even  it  the  procedure  ha. 
been  conducted  under  anesthesia  sutlicient  to  abolish  sensation. 
2.  Vain  oTJ'iijht,  without  gross  injury  to  peripheral  nerves. 

3  Severe  heworrhaqe,  either  external  or  internal. 

4  loss  of  fliiiih  as  in   i)ersi>tent  vomiting  or  excessive  diarrlura. 
\Ve  are  ai)t"to  count  the  two  latter  as  collapse,  the  others  as  shock. 

In  svncoi.e.  shock,  aiul  c.llapse,  there  is  a  combination  of  cardio- 
vascular disturbance  with  -rave  iirrest  of  cerebral  activity.  1  he  primary 
xascular  disturbance  is  sometimes  easily  understoo.  .  /  ''^  ,y*"'^"^'^,^ 
„f  the  splanchnic  area,  or  even  of  the  liver,  are  capable  of  holding  a.l 
the  blood,  but  thev  do  not  onlinarily  do  so  because  ot  the  tone  ot  the 
abdominal  walls,  comi.ressing  the  viscvra.  and  the  tone  ot  the  vessel 
waIN  bv  which  arteries  and  v.-ins  are  in  a  state  ot  partial  contraction. 
If  fn.m"  anv  cause  there  i-  rapi.l  .iilatation  of  the  abdominal  veins 
the  blo..d  in  the  upi.cr  half  of  the  bo.ly  may  gravitate  there  in  increased 
am.>urt,  vvith  eorresi.onding  an..mia  of  the  brain.  ()nc  can  even  pro- 
duce 1  neonsciousness  by  eo:npression  of  both  carotid  arteries.  Ihis 
abdominal  vasodilatation  may  be  cause.l  by  a  blow  upon  theahdomen. 
which  produces  inhibition  of  th.  splanchnic  vasoconstri<'t..r  influences, 
whereby  the  ab.l.)minal  veins  become  dilate.l,  or  stimulation  ot  ttu' 
canliac  inhibitorv  centre  (vagus)  whereby  the  heart  beat  is  arreste.l. 
One  ..r  both  of  tlu-e  influences  may  be  at  work  to  constitute  tlie  ettect 
of  the  "'^.'lar  plexus  bl.>w,"  known  to  the  prize  ring,  \\here  by  aii> 
„f  these  means  there  is  produced  merely  a  temporary  cerebral  anemia, 
we  have  the  eondilion  .»f  .^vnc()pc. 


'■.■'■irmi^^-3'. 


PAIN 


179 


\Micn  ail  attcinpt  is  made  to  .l«-fiiic  tiie  condition  of  shock,  it  miist 
l.(.  ninonilKTcd  tiiat  depression  or  cessation  of  fnnction  is  a  j)roniinent 
t.ainrc  Tins  sccnis  to  apply  t..  the  individual  cell;  for  it  has  been 
noted  that  drn};s  like  alcohol,  ether,  and  strvchnine,  administered 
liuring  shock,  are  inert,  although  they  dilfuse  perfectlv;  vet  with 
nroy.Ty  of  the  cells,  the  physioloj;!,,.!  dicct  has  been  seen  to  assert 
II Mil,  indicatm;;  that  the  actual  metabolism  of  the  cell  was,  for  the 
tune,  suspended.  It  has  been  observed,  too.  that  in  shock  the  specific 
jiravity  of  the  blood  falls,  and  that  of  the  tissues  rises,  indicating  a 
l..issai;e  ot  tissue  juic.s  to  the  l)loo<l,  which  accounts  for  the  rapid  pro- 
.In.tion  ot  the  "sunken"  appearance  of  the  eyes  and  the  proniii.nce 
()!  the  cheek  bones.  Precisely  the  same  relationship  between  the  blood 
:Mid  the  tissues  has  l)een  found  to  occur  in  cases  of  large,  rapidlv  pro- 
'In.rd  liemorrhag.-.  If  a  clinical  distinction  is  to  be  made  between" shock 
:ni'l  cnllapse,  it  is  that  in  shock  we  regard  the  nervous  .listurbance 
:i;  initiating  the  circulatory  dej)ression,  and  that  in  collapn-  we  con- 
^i.lrr  the  depression  as  being  caused  by  the  continued  cerebral  anemia 

Acapnia.—^  andell  Henderson  ascribes  the  sequence  of  changes  in 
til.'  b!oo.  pressure,  the  filling  of  the  splanchnic  veins,  ^he  rapid  ai.d 
vMiikeiied  heart  action  seen  in  shock,  not  to  primary  vasomotor  influ- 
.  ii.cs  but  to  acapnia,  or  the  effects  of  diminished  carbon  dioxide  in 
t  I.'  i.lood  .exposure  of  the  viscera  and  the  mere  aeration  of  the 
:il"ioininal  cavity  by  this  meuis  is  accompanied  by  exhalation  of  carbon 
HhiM.le,  and  aflords  the  an.iomical  and  clinical  picture  of  shock  If 
I  M  ..xp„se.l  Mscera  be  })athed  with  salt  solution  saturated  with  carbon 
.li.-M.le,  the  condition  is  arrested.  This  may  well  explain  certain  cases 
ol  Mir-LMcal  shock,  and.  mdeed,  ai)i)lying  these  views,  supervention  of 
^Ip  k  has  been  prev.>nted  by  indivi.lpal  surgeons.  We  doubt,  however 
"Ixilier  acapnia  and  shock  are  identical  and  whether  this  diminution 
'"  ■  :irl.on  .  loxide  is  to  be  encountered  in  all  cases.  The  rapid  on<-..me 
"I  '  I.;  cnduion  in  some  cases  is  evi.Iently  a  reflex  act,  and  a  general 
ni.  ilutiun  ot  the  activity  of  the  higher  lerve  centres  must,  in  these 
'l'--  at  least,  precede  any  change  in  the  carbon  dioxide  content  of 
t!i'    lilood. 

if  .loervcs  to  be  notcl  that  it  has  been  determined  practicallv  that 
!!'•  conrs,-  of  surgical  operations  the  exhibition  of  carbon  (jioxide 
t^  the  dcveloi)inent  of  shock,  even  more  surelv  than  does  Crile's 
•ration  ol  the  old  method  of  compressing  the  extremities  and 
"■  >n  as  to  bring  about  filling  of  the  more  central  vessels.  There 
"■k  ot  any  evidence  that  in  shock  the  arteries  undergo  dilatation 


PAIN 

<  IS  the  cry  of  the  tissues.     The  infant  cannot  explain  its  dis- 

•ts  and  expresse.;  them  I>y  crying;  equally  the  tissues  have  no 

"t  expressing  to  the  individual  that  something  is  wrong,  save 

i)re.s,iRc  of  the  sensation  that  need  not  be  <' .fined  because 


III 

Ml'! 


lilt 
I,.. 


m 


180 


TffH:  MORBID  AND  REACTIVE  PROCESSES 


9 


•I 


universally  experiencvd-  pain.  Paradoxical  as  it  seems,  pam  cannot 
exist  in  the  tissues;  a  pain  in  the  foot  is  ii  ilisturhance  of  those  nerve 
cells  in  the  brain  whose  function  is  to  receive  stinnili  conveyed  to  them 
by  the  afferent  nerves  from  tl  .    region. 

In  this  connection  we  mu-  .  recognize  two  orders  of  tissues,  irrita- 
tion of  either  of  which  may  set  up  the  sensation  of  i)ain,  but  in  the  one 
this  process  is  accurately  localized,  while  in  t'.ie  other  the  sensation  is 
localized  by  the  brain  as  originating  in  some  other  area  or  areas.  Of 
the  former' may  be  mentioned  the  skin,  the  mucous  membrane  of  the 
mouMi  and  pharynx,  the  skeletal  muscles,  the  i)criosteum,  and  the 
tunici  vaginalis  of  the  testis;  of  the  latter,  all  the  viscera,  with  the 
exception  of  the  testis,  or  more  accurately,  of  its  serous  coat.  This 
may  seem  to  be  a  sweeping  and  unfounded  statement  and  one  contrary 
to  personal  experience,  but  as  a  matter  of  fact,  the  individual  viscera 
may  be  handled  with  impunity  and  even  be  cut  in  the  unanesthetized 
individual  without  any  sensation  being  induced.  In  such  organs  there 
are  no  sensory  nerves  for  pain,  no  direct  paths  whereby  the  conscious- 
ness is  informed  of  disturbance  in  those  particular  viscera.  Stating 
this,  we  do  not  mean  to  indicate  that  pain  may  not  originate  from  the 
viscera;  every  schoolboy  knows  a  stomach-ache  as  a  yery  real  thing, 
and  undoubtedly  a  dull"heav>  pain  follows  pressure  or  serious  traction 
upon  these  yiscera.  though  here  again  we  are  unable  to  localize  the 
pain  in  any  particular  area.  At  most  we  liave  an  obscure  localization 
of  something  wrong  inside.  When,  for  example,  the  oesophagus  or 
stomach,  or  the  colon  is  overdistended,  there  may  be  painful  sensa- 
tions behind  the  sternum,  in   the  upper  or  lower  abdominal  areas 

respectively.  u    i     •  i.        i 

If  we  analyze  the  pain  associated  with  disturbances  ot  the^  internal 
yiscera,  we  encounter  some  points  of  remarkable  interest.  Take  for 
example,  the  organ  just  noted- the  stomach.  An  ulcer  or  other  acute 
lesion  of  this  viscus' is  found  to  afford  a  pain  which,  if  the  patient  be 
asked  to  localize  it,  is  situated  in  the  ahdominal  wall  in  the  epigastric 
region.  We  mav  e\en  oV)serye  that  if  the  lesion  be  in  the  cardiac  part 
of  the  stomach,"  the  i)ain  is  in  the  upper  part  of  this  region,  if  toward 
the  i)vlorus  in  the  lower,  and  this  irrespective  of  the  fact  that  th.' 
car.liac  and  pyloric  regions  lie  somewhat  transversely,  rather  than 
vertically  one  above  the  other.  In  addition,  the  patient  endeavors, 
and  if  he  be  at  all  stout,  endeavors  in  vain,  to  touch  an  area  in  the 
dorsal  region  between  and  rather  below  the  shoulder  blades;  more 
accuruielv  on  cither  side  of  the  seventh  and  eighth  dorsal  yertebne. 
With  the  heart,  as,  for  example,  in  angina  pectoris  where  the  pain  is 
extreme,  it  is  noteworthy  that  it  is  complained  of  as  existing,  not  in 
tlie  organ  its.-lf  but  over  it.  There  is  frequently  felt  ;.  ->  a  sens('  "f 
extreme  constriction  along  the  line  of  the  second  rib,  and  with  tins, 
further,  a  pain  extending  down  the  inner  side  of  the  left  or  occasioiia  y 
the  right  arm,  or  both,  most  often  as  far  as  the  elbow,  and  occasionally 
as  far  as  the  little  finger  and  the  ulnar  side  of  the  ring  finger. 


PAIN 


181 


It  is  to  English-speaking  observers  more  particularly  tliat  we  owe 
tli<-  study  and  elucidation  of  these  so-called  referred  i)ains.  Hilton, 
in  his  well-known  lectures  on  "Rest  and  Tain,"  piiblishc<l  in  1863, 
luid  a  very  clear  realization  of  their  existence;  their  full  study,  however, 
\\v  owe  to  James  I{oss,  Dana,  James  Mackenzie,  Head,  and  Hertz. 

Fio.  58 


Hiprcscnlalion  of  primitive  vertebral  animal— the  ampliioxus— divided  tor  convenience  into  three 
-lUMiinia  for  the  head,  seven  for  the  neck,  twelve  for  the  dorsal,  nine  nr  the  liimbos:icral  reuion,  and 
111  indefinite  nimiber  for  the  coccygeal  rcKicm:  SI'D,  the  Bupcrior  primary  divisiiu  ■<  of  the  nerves 
-u|.pl.\  iiiK  the  surface  over  the  neural  canal;  IJ'IM,  the  dorsal  trunks  of  the  inferior  primary  dittsion 
Mippl.viPK  the  lateral  surface  of  the  body,  and  IPDr,  the  ventral  trunk  of  the  inferior  primary  divi- 
siiii,  snpplyinx  the  ventral  surface.  The  parts  supplied  by  the  dorsal  trunks  of  the  interior  division 
art;  alone  lined.     (Ross.) 


PiMiiriini  slu.winK  constitution  of  a  spinal  nerve:  C,  spinal  cord;  Pr,  or,  posterior  gangi' ited  and 
CUT,  ricr  non-gangliated  root  cf  nerve  respectively;  SPD,  superior  primary  division;  IPD,  inferior 
i  in.iry  division;  d,  v,  the  dorsal  and  ventral  branches  respectively;  Sr,  sympathetic  (gangliated) 

1"    '         llioss.) 


I".;n;h  segnient  of  the  body  has  in  the  earliest  vertebrate  types,  e.  g., 
iiiiiphioxus,  its  segmental  nerves,  and  marked  as  has  been  the  evolu- 
t;  .11  i)f  the  nervous  system  of  the  higher  vertebrates  this  segmental 
;!n;iiij,'einent  still  persists,  the  segments  being  composed  of  the  neurones 
"I  the  po.sterior  ganglia  (sensory),  the  neurones  of  the  anterior  horns 
uiinior),  and  the  neurones  of  the  sympathetic  system.  Each  segment 
of  ill.'  ImhIv  has  thus  its  system  of  sensorj',  motor,  and  sympathetic 


IT      V"*" 


182 


THE  MORBID  AND  REACTIVE  PROCESSES 


im  ii  -i; 


}«     J- 


s*  •  •■  f  I  • 


nervts,  these  latter  beiiiK  ot  both  onlers,  sensory  and  motor.  In  the 
process  of  devehtpnient  tlie  various  groups  of  nerves  cotne  to  lie  in 
different  planes,  the  sympathetic  motor  neurones,  for  exami)le,  becom- 
ing grouped  into  ganglia,  some  of  which,  e.  r/.,  the  cervical,  represent 
the  fusion  of  the  neurones  of  several  segments.  So  also  the  superficial 
sensory  nerves  do  not  necessarily  lie  in  the  same  plane  as  do  the  muscles 
supplied  by  the  motor  nerves  of  the  same  segment;  every  schoolboy 
sliould  know,  although  he  may  not  have  analyzed  the  fact,  that  the 
region  of  the  buttocks  is  supplied  I  sensory  nerves  originating  from  a 
singularly  large  number  of  spinal  segi.icnts;  while  as  regards  the  internal 
viscera  such  as  the  heart,  stomach,  and  intestines,  these  with  their 
associated  nerves  come  to  lie  widely  remote  from  their  original  segmental 
position,  both  actually  and  relatively.  Thus  to  explain  the  instances 
given,  the  stomach  is  innervated  from  the  level  of  the  seventh,  eighth, 
and  ninth  dorsal;  this  region  also  affords  the  sensory  nerves  which 
on  the  posterior  aspect  of  'le  body  supply  the  lower  tlorsal  region 
between  the  shoulders  and  m  front  innervate  the  abdominal  wall  of 
the  epigastric  area,  the  anterior  muscular  branches  innervating  the 
corresponding  intercostal  spaces. 

The  sympathetic  nerves  of  the  heart  are  relatively  abundant  and 
vary  for  the  different  regions;  thus  the  auricles  are  innervated  from  the 
fifth  to  eighth  dorsal  ser'nents,  the  ventricles  from  the  second  to  fifth 
dorsal,  the  ascending  arch  of  the  aorta  from  the  third  and  fourth  cervical, 
and  the  first,  second,  and  third  dorsal.  The  referred  pains  vary  accord- 
ing to  the  part  involved,  and  it  appears  also  that  if  the  right  heart  be 
involvefl  they  show  themselves  on  the  right  side  of  the  body,  if  the 
left  heart,  then  on  the  left.  The  referred  pains  in  angina  pectoris  are 
most  frequently  along  the  superficial  area  of  innervation  of  the  ven- 
tricles, notably  along  the  superficial  sensory  area  belonging  to  the 
second  dorsal,  extending  also  when  severe  into  the  first  dorsal  segment. 
We  are  accustomed  to  regard  the  auricles  as  the  beginning  of  the 
cardiac  region,  and  so  would  expect  that  they  should  be  innervated  from 
the  higher,  the  aorta  from  lower  segments.  If,  however,  we  study  the 
development  of  the  heart  we  find  that  this  begins  as  a  simple  tube 
which  becomes  bent  upon  itself  in  an  S-shaped  manner;  it  is  the  inferior 
or  "  caudad"  portion  of  this  tube  that  gives  rise  to  the  eventual  auricles, 
the  superior  or  "cephalad"  that  becomes  the  first  part  of  the  aorta. 

What  happens,  therefore,  in  those  cases  where  pain  is  experienced, 
is  that  stimuli  proceeding  from  these  internal  ^•iscera  to  the  neurones 
of  a  particular  level  of  the  cord,  do  not  extend  thence  directly  to  tlie 
cerebral  cortex;  no  mechanism  exists  for  this  direct  communication; 
but  where  the  stimulus  is  above  a  certain  grade  there  is  an  irradiation 
or  expansion  of  the  stimulus  to  other  neighboring  neurones  which  do 
possess  this  communication  with  the  optic  thalamus,  and  as  a  come- 
-juence,  the  brain  localizes  the  seat  of  disturbance,  not  in  the  viscus  origin- 
ally disturbed,  but  in  the  areas  innervated  by  these  neighboring  neurones. 
It  deserves  note  that  pahiful  sensations  have  their  scat,  not  as  might 


Nil 


PAIN 


183 


l)c  fxpected  in  tiie  cortex  of  tlie  hemispheres,  hut  in  the  thalamus. 
Ihe  cortex  may  be  cut  into  without  ^nvinj,'   rise  to  anv  sensation; 
irritation  of  the  thalamus  of  one  side  leads  to  pains  referred  to  the 
other  sKe  of  the  body,  its  destruction  to  anesthesia  of  that  other  side. 
1  us,  liowever,  is  not  everything.    If  lonp  continued,  this  segmental 
irradiation  induces  a  condition  of  lieiRhtened  irritability  in  these  neiL'h- 
l)oniig  neurones,  the  result  of  which  is  that  minimal  "stimuli  reaching 
them  have  maximal  effects,  so  tliat  the  areas  supplie<l  bv  their  sensorv 
l.ranches  become  hyperestiietic;   and  the  irradiation  affects  the  neu- 
rones also  of  segments  above  and  below,  and  thus  not  merely  is  the 
sense  of  pain  localized  in  these  other  areas,  but  these  other  areas  become 
the  seat  of  actual  hyperesthesia,  so  that  now  a  stimulation  of  these 
areas,  as  by  pricking  or  pressure  or  traction,  gives  the  sensatior  of 
acute  pam.'    More  than  tiiis,  as  has  been  pointed  out  in  the  discussion 
..t  inHammation,  there  may  be  a  general  vascular  disturbance  of  such 
an  area,  giving  a  so-called  sympathetic  inflammation.     Further,  as 
we  have  already  indicated,  the  area  of  cutaneous  supply  does  not 
correspond  absolutely  with  the  segmental  innervation  of  "the  under- 
lynig  muscles.     In  the  first  place  we  may  recognize  with  Mackenzie, 
a  sui)erhcial  and  a  deep  cutaneous  hyperesthesia,  possibly  correspond- 
ing to  the  differing  distribution  of  the  tactile  and  painful  senses,  of 
whicfi  the  latter  at  times  is  found  present  without  the  former  (although 
It  seems  that  when  superficial  hyperesthesia  is  elicited,  the  deep  is 
always  present),  aiul  in  addition  a  yet  deeper  muscular  hyperesthesia, 
lo  give  an  example,  where  there  is  enlargement  of  the  liver,  the  com- 
monest pain  felt  is  over  this  organ,  and  inasmuch  as  this  is  markedly 
increased  by  pressure,  the  ordinary  impression  is  that  this  is  an  actual 
sijlanchnic  or  visceral  pain.    If,  however,  the  area  be  mapped  out  over 
winch  pressure  causes  pain,  it  will  be  found  to  extend  considerably" 
heluw  the  edge  of  the  liver,  and  if  the  abdominal  wall  be  piciied  up 
over  this    rea  the  muscle  is  exquisitely  painful.    There  is  here  not  a 
Miperhcui  out  a  deep  muscular  hyperesthesia  of  tiie  abdominal  wall. 
Ue  hi  ve  here  but  touched  upon  the  outlines  of  the  subject,  but 
i.el  that  both  for  comprehension  of  disease  and  as  an  aid  in  diagnosis 
tins  s.udy  of  painful  areas  is  of  the  very  first  importance,  even  if  hitherto 
It  has  not  been  discussed  in  any  text-book  of  general  pathology  known 
t'.  us.    We  would  conclude  by  giving  an  indication  of  a  few  important 
arias  of  referred  pain   without  exact  anatomical  description.     The 
-titcti    of  pleurisy  is  not  due  to  the  presence  of  sensory  nerves  on  the 
pl«  nral  surface— experiment  shows  that  the  pleura  are  ins  -nsitive-  but 
It  IS  due,  according  to  Mackenzie,  to  spasm  of  the  intercostal  muscles: 
It  1^  thus  a  referred  muscular  pain.      None  of  the  serous  surfaces  have 
.  nsory  nc-ves  proper,  with  the  exception  of  the  tunica  vaginalis  testis. 
\^  the  testis  descends  into  the  inguinal  canal,  it  carries  before  it  certain 
'  iinents  jf  the  abdominal  wall,  -he  cremasteric  muscle,  etc.,  ard 
ainii-  With  these  the  genital  branch  of  the  genito-crural  nerve.     In 

0  ■  ofZ.^I^J'wi!?^'^''  ^^"K^  ^''^.^^  '^^^"^^  ^'"'^^'^  disturbance  the  mapping 
0     01  hypereathetic  zones  is  of  prune  diagnostic  importance. 


184 


THE  MORBID  A'  n  REACTIVE  PROCESSES 


^B^^^^  [i 

those  having  a  long  cord  it  i  ,isy  to  (ietermine  that  pressure  upon 
the  testis  causes  immediately  acute  pain  localized  in,  or  more  accurately 
upon  the  testis,  and  following  upon  this  a  referred  pain  is  felt  in 
the  groin.  So  also  the  lower  end  of  the  ureter  is  innervated  by  the 
genito-crural  nerve,  and,  per  contra,  with  arrest  of  a  stone  in  the  '.reter 
there  is  a  referred  pain  in  the  testis.  We  have  said  that  the  other 
serous  membranes  are  insensitive;  this  statement  is  made  with  a  full 
recognition  of  the  fact  that  traction  upon  the  peritoneum  in  the  un- 
anesthetized  person  may  be  attended  by  pain;  but  thi.s  pain,  again,  is 
not  accurately  localized  but  is  referred.  We  may  lay  down  that  trac- 
tion upon  or  injury  to  the  stomach  is  referre<l  to  the  epigastric  portion 
of  the  abdominal  wall,  of  the  small  intestin  to  the  umbilical  area,  of 
the  large  intestine  to  the  hypogastric  area  "Se  localization  of  appen- 
dical  disturbance  is  well  known  to  be  uk  .en  felt  at  what  is  known 
as  "McBurney's  point."  Irritation  of  th  madder,  as  in  vesical  calculus, 
is  characterized  by  pain  felt  in  the  urethra,  especially  at  the  extremity 
of  the  penis,  by  reason  of  their  common  innervation  by  the  third  sacral 
nerve.  The  rigidity  which  is  observed  in  the  abdominal  wall  accom- 
panying intestinal  lesions,  is  another  manifestation  of  the  "viscero- 
muscular"  reflex.  Decks  has  recently  called  attention  to  the  existence 
of  a  doughy  inelastic  skin  over  the  abdominal  wall  in  almost  every 
chronic  inflammatory  lesion  of  the  abdominal  viscera. 

Finally,  the  bram  itself  is  devoid  of  sensation;  headache  is  not  pain 
of  the  brain,  but,  as  will  be  recognized  upon  consideration,  is  a  super- 
ficial phenomenon,  due  to  irritation  to  one  or  other  of  the  cranial  nerves, 
or  in  the  case  of  occipital  headache,  of  the  spinal  accessory  and  second 
cervical  nerves.  The  brow-ache  experienced  after  an  ice  has  been 
eaten  in  haste  Is  due  to  the  fact  that  the  sensory  nucleus  of  the  fifth 
nerve  has  been  stimulated  by  irradiation,  the  afferent  nerves  of  the 
oesophagus  being  in  the  main  vagal,  and  the  vagus  nucleus  being  situated 
close  to  that  of  the  trigeminal. 

In  short,  to  quote  James  Mackenzie,  "the  sensation  of  pain  from 
whatever  source  the  stimulation  arises,  is  referred  to  the  peripheral 
distribution  of  sensory  nerves  in  the  external  bofiy  wall."  This  source 
may  be  (1)  in  the  brain  itself,  as,  for  example,  where  an  epileptic  attack, 
due  to  cerebral  irritation  begins  with  pain  in  the  distant  part  (aura);  (2) 
in  the  cord,  e.  g.,  the  girdle  pains  of  tabes  dorsalis;  (.3)  in  the  posterior 
root  ganglia,  e.  g.,  the  pain  of  herpes  zoster;  (4)  in  the  viscera,  of 
which  numerous  examples  have  been  quoted,  or  (o)  in  the  external  body 
wall  and  skeletal  muscles,  where  only  (with  the  exceptions  noted)  the 
pain  informs  us  of  the  actual  seat  of  the  disturbance. 

Finally,  while  speaking  thus  broadly  of  pain  it  must  be  kept  well 
in  mind  that  there  are  various  and  distinct  orders  of  sensory  nerves, 
disturbance  of  any  one  order  of  which  gives  rise  to  the  sensation  of 
pain,  namely,  nerves  for  the  tactile  sense,  for  the  muscular  sense,  for 
heat,  for  cold,  not  to  mention  yet  other  orders  the  existence  of  which 
is  evidenced  by  the  researches  of  Head  and  Mackenzie. 


<'IIAPTKR    IV 

PK0C.RES8IVE  TISSUE  CHANGES 
0ENE»A1  CONHDEBAnON  OF  TISSUE  CHANOES 

tH.ns  produced  in  the  tissu^-s     T  11-        .    1     ^'^^^'^'^^^  to  the  aJtera- 

".at  the  factors  deterSfn,  it;heakh  or''''  ^""y.'^"^'  ^"'  ^^  «- 
mjtrition  of  the  cell  and  miJt  !•  •  '"^  normality  are:  (1)  the 
-e  intimately  de^Tn't  Sof  o  raS"ef  "1^^'*^''  ^"^/"^-^  *- 
r  ""  rt^e  one;  only  that  f^l  Sch  fof  ;>,  P''^^^^^  «'  nutrition 
•e  assimilated,  and  assimilatiris  nmlfil  hlfl.  TP^'  H"?'*''^  *«"^«  *" 
.""ction  is  necessary  as  well    th!!  '^  *''^  ""*"*'on  ««"  occur. 

I^its,  the  more  actiVe  the  absortirnf ""''''  '^'  /""^*'«''>  ^'tf'i" 
tl'e  function  the  less  the  demand  S  •  ".^  .'"at«ri«I.  and  the  less 
'<'od  and  function  are  seen  t^h    •      f'.«™''at'on.    The  two  factors 

Although  the  subS  has  b^'en'ST^'^'  ^"""'^  *°  «"«  «nothe  .' 
^'■"cral  principles  to  l^remZC:r^tior'''''u''^^^^ 
.f'.t. inadequate  nutrition  or  laTof  '    rctj^  ff  ^"'i"  recapitulated; 
";an.tion  and  shrinkage  until  arresf  of  fnn  7        """*'""  '"^>'  '^"^  to 
tl.a^  .xce'-sive  activity  mav  so  rSv  ,,1         .u  ""'  f.'\"  ^^"t*^  ^"«"es; 

■;-',tr.t.on  may  lead  to  growth  and  Zit'  ^^^r^^"'"^^  ^>'  ^^^"ate 
''"^  time  on  a  higher  level  f-^.'^fa^  ^"'^'^num  be  once  more  reached 
r-'l'"  on  which  it  w^rks  w  ihou  ?oss' oTT " *''"  ^"l'"^"  '"^-««-  t^e 
t-;  between  cell  mass  and  ceU  surfLe  anr"'^V  '^''  '^''^  '«  «  '•^'«- 
>''r  ace,  so  that  increase  becomes  sdfinhy.  'f'^'  "'^''  «"^  »»«'«" 
P-l'  eration  occur;  that  grow  hanfnn.T  »"^J^ar 

" I'l'l'  can  occur  simultaneously  oXtilh?"  «''^.°PP«««^  Processes, 
^"-n  of  the  cell  for  and  th  S  the  nl%"^''""^  ^'^ 
srouth  and  proliferativrcanaS^ht  ^f ".f^M"", '^^  ^"°^*'«n  J^-'ts 
""t  proliferate,  and  that  the  rctiVev.l^'i^'^'''^'.?^^'^'«P«d  cell  does 
«^"  ti..,se  that  have  ne^er  £^^^11  Tff  ''^ -"""^  "^  *h^  «'-g«n»m 
''>;'.'  'li'ferentiated,  ha^e  reverted  fl^'^^^'J'*'"*^.^^  ^'^  '^  ^^^^  have 
''  ^ve  pass  from  physfoloSlo  L^^^^^^^^  ^^P^- 

^  at  once  the  qLstion  f'to  the'^autTf  r^'*\"'  overgrowth. 
-'•  .rowth  originates  who^  fnTh/cite ^^^^^  ^^ 


tiuit 


l!AU 


.,t    .. 


180 


PhOGRKSSIVE  TISSUE  Clf.XNGKS 


'4  :J  -'i 


cell  growth,   i.  e., 


^stimulus  to  jcrowtli  outside  the  cell  d(K's  not  exist,  a  fmiiit  of  view  v.hich 
we  cannot  share.  It  seems  lik«'Iy  that  ^trowth  depends  somewhat 
ujjon  tension  of  su  rnundinR  cells,  or  In'tter  that  growth  is  restrained 
by  the  eH'eet  of  siirromiding  cells,  hut  it  appears  that  this  cannot  be 
all,  for.  more  powerful  than  the  restraininR  effect  of  the  surrounding 
cells,  an  external  stimulns  may  arise  that  is  powerful  enough  to  more 
than  neutralize  these  influences. 

We  find  that  there  is  a  c'onsid«'rablc  numl)er  of  circumstances  or 
combinations  of  circumstances  tliat  may  lead,  on  the  one  hand,  to  cell 
overgrowth,  or,  on  the  other,  to  cell  shrinkage  and  degeneration. 

Thus  overgrowth  may  arise  from: 

1.  Normal  activity  with  increased  nutrition. 

2.  Increased  activity  with  iiicrease«l  nutrition. 
:{.  Ueduction  in  the  external  forces  inhibiti   i: 

diminished  tissue  tension. 
These  changes  in  tissue  we  call  progressive. 
.*>hrinkage  and  degeneration  may  arise  from: 

1.  Normal  activity  with  rcfluced  nutrition. 

2.  Normal   activity   with   pervi-rtcd    nutrition, 
being  of  the  wrong  kind. 

3.  Increased    stimulation    or    overstimulation 
relatively  insufficient  nutrition. 

4.  Arrest  of  function. 

5.  Increase  in  the  external  forces,  arresting  growth. 
These  changes  are  regressive. 

Hut  these  classes  do  not  cover  all  cases.  It  w''l  be  remembered 
that  there  is  a  group  of  cases  in  which  the  changes  are  not  so  evident 
in  the  protoplasm  as  in  the  paraplasm  (a  single  example  is  the  so- 
called  fatty  degeneration j,  and  since  these  changes  are  either  due  to 
or  lead  to  regressive  changes  in  the  protoplasm,  they  are  includeil 
among  the  regressive  changes.  On  the  other  hand,  there  is  the  important 
series  of  the  neoplasms  in  which  one  cannot  state  what  is  the  primaiy 
cause  of  the  excessive  overgrowth;  these  are  naturally  included  among 
the  jjrogressive  changes. 


the 


aii<i 


food   material 
activity    with 


;  I- 


OVERGROWTH 


Overgrowth  of  i  tissue  in  which  the  individual  elements  preserve 
their  physiolog*  il  relationships  and  functions  may  be  shown  by  an 
increase  in  size  of  the  individual  element  —  hypertrophy  —  or  by  an 
increase  in  number-  hyperplasia' — or  by  both  together.  Pseudohyper- 
trophy is  something  entirely  distinct;  here  exists  an  actual  atrophy  of 
the  individual  elements,  with  replacement  in  excess  by  another  tissue 


HI 


'  Sninp.  prpfpr  to  call  these  simple  and  n  imerical  hyperplasia  respectively,  which 
ia  more  accurate  but  less  widely  used. 


OVERGROWTH  jgj 

(Fig.  60).  In  the  s..-.«IIed  " pseiuJohyiHTtronhic  tmralvsis  "  th.. 
M.m.„se  .n  s.ze  of  the  muscle  is  due  to  «„  L^•essi^'^  ,'ten"  Si  Svelot! 
.nent  of  fa  cells,  while  t  he  muscle  fil.res  are  degeneraS  «„  ?1  „t.  isS 
n  s.ze  and  uj  numhcr.    It  mu.t  be  underst^Kj  that  Im  XX' a^d 

elements  of  the  ofk.,-  concern«l-  the  liver  cells  in  the  l.scr  the  nmscle 
x'll  u.  the  muscle  .anatomically  defincl)  an.l  so  on.     I  v^rtrS^ 
t.elf    s  a  nusleadmg  term,  etymologically  it  n.ear.s  "o>.;m.t     i'on^: 
Imt  scientifically  it   means   nothing  of  rnuiriuon, 

u.e  sort;  the  term  is  so  widely  used  in  f.o.  eo 

Its  generally  accepted  sense  that  it 
would  be  inadvisable  for  us  to  employ 
it  otherwise. 

Kinds     of    Overgrowth.  —  !.  Physio- 
logical Hypertrophy.— The  type  of  this  is 

the  jiregnant  uterus,  which  enlarges  by 

liM>erirophy  and  hyperplasia.  The  total 

Mze  in  cubic  content,  of  the  hyjwtro- 

plK.-d  muscle,  is  many  times  in  excess 

<»t  the  normal;  a  great  increase  in  blood 

supply  also  occurs,  and  muscular  con- 
traction begins  from  an  early  period  of 

pregnancy.     Increased  nutrition  cannot 

1)0   said   to  be  the  chief  cause  of  this 

mergiowth,  because  the  presence  of  a 

fibroid  in  the  uterus  for  example,  unac- 

•  ompanied  by  any  marked  increase   in 

\ascularity,    may    be    associated    with 

«reat  hypertrophy.     The  excessixe  de- 

\  eiopme.'it  of  muscles  by  exercise,  as  in 

tlie   blacksmith's  arm,  is  certainly  due 

partly  to  activity,   but  with  increased 

nutrition,  because  a  muscle  during  exe 

tS.f  SlT  underr'"^  "TJ"''""  '^''''''^  '*•    ^^^''^^'  '«  "«*  t^e  only 

just  as      ih    u trthe  fibr  Jh"*^   1  '^'  ^T  ""'  ^'^'^^^^  •"  ^'hich. 
I'cart  weight  is  >50  to  -S^l        become  larger  than  normal;  the  normal 


Longitudinal  section  through  muscle 
of  calf  of  leg  in  pscudohype-t-ophic 
paralysis.  The  muscle  fibres  exhibit 
atrophy;  the  increase  in  bulk  is  due  to 
the  eicessive  development  of  fat  cells 
(Orth.) 


PROGRESSIVE  TISSUE  CHANGES 


188 

times  calle.1  compewtory.  a  t.-rn.  M  ought  t     h-  «stncte<l 

„f  ,b„K., .,  wiKT.  o„....t .  ,,.ir  o  „,K„„, ';';;"-;;'  ,;^;';™;„i 

.he  „.h.,  may  .r.,.;  ...  .I.,.  .»  o      u-  .-j;  »    -':^  ^  ^le  .i  Im 
™  y  „™ltl  f.n,o.i,.n,  u..k.rtuke  .!..■  work.  "Vl  "X;:;.';,:^^" 

increased  activity  (as  by  the  increased  warmth  of  the  part;  before  thej 


RKC.KSF.  RATIOS 


180 


can  utili/.e  the  oxctv s  of  nutrition  that  is  around  tlum.  Thero  is  rxj)eri- 
int-ntal  fvidnuT  timt  incriasiMl  tfnip<Tnture  of  a  part  stimuliit.-  erowth: 
a  lahbit'a  oar,  k»-pt  warm,  iH-conu-s  of  a  creater  size  than  '  \[-""^^, 
which  has  Ihh'U  Itcpt  at  a  normal  tcmpc  aturc.  What  then  will  (  II 
them  into  the  re<iuin-«l  activity?  Many  stimuli  are  ahle.  and  some  of 
these  relativf 'v  slight  ones,  such  as  the  constitution  of  the  fluid  that 
hathes  the  cell  with  reference  to  its  oxyRen  and  carlH.n  ditixide  content, 
to  say  nothing  of  the  external  nervous  and  other  stimuli  which  we  are 
more  accustome<l  to  hear  in  mind.  , 

There  must  Ik-  inclu.led  in  this  group  the  h\  .ertrophies  oc<'urrinR 
in  n.vxa'dema  and  acroincKaly,  diseases  which  .isi-  in  jH-rsons  wlu)se 
internal  secretions  are  disturlnMl;  myxtrdema  -ts  when  the  thyroid 
secretion  is  deficient  nr  absent,  and  exhibits  i  excess  of  inCorstitial 
mucin  in  the  tissues,  and  subsequently  a  real  overgrowth  of  the  sujh 
portive  tissues.  Similarly,  acromegaly  is  an  overgrowth  of  the  bones  of 
t'-e  head  and  the  extremities,  a;:^)ciate<l  with  disease  of  the  pituitary 
Ixxlv.  These  are  evi<!<  'y  cases  of  nutritional  overgrowth,  which  arc 
instituted  bv  some  st".uiius,  ordinarily  held  in  check  by  an  internal 
secretion  and  possiblv  .  a  chemical  nature.  Not  far  removed  from 
this,  is  the  form  of  over;,'rowth  which  is  called  sym|)('thetic,  such  as 
the  overgrowth  of  breast  tis  ue  in  pregnancy;  thiK  \  uild  be  frankly 
classed  among  the  physiologi'  al  overgrowths,  save  lor  the  fact  that 
it  is  due  to  something  of  the  nature  of  a  hormone,  as  shown  by  the 
enlargement  of  the  breast  that  occurs  in  the  non-pregnant  animal 
inoculated  with  an  extract  of  fa-tal  tissue  or  corpus  luteum. 

During  the  consideration  of  nutritional  overgrowth,  we  must  not 
lose  sight  of  the  fact  that  abundant  nourishn.ent  is  most  effective 
when  couple*!  with  some  activity,  but  that  occasion  lly  the  stimulus 
to  activity  is  given  by  the  increased  nutrition  its»  this,  however, 
is  no*  to  be  depended' upon,  and  generally  the  opix  e  is  true,  that 
the  activity  of  function  must  precede  the  o  ^^rprowui;  this  activity, 
too,  must  not  be  excessive  f)r  the  result  will  i  uor  overgrowth,  but  the 
contrary,  atrophy. 

Simulated  Overgrowth.— Somet.  e  wc  oetn  to  soe  examples  ot 
.xcessive  overgrowth,  which  are  ..ut  really  s-i'h;  an  example  is  seen 
in  the  occasional  enormous  development  of  certain  teeth  in  anitnals. 
These  teeth,  ordinary-  opjwsed  to  other  teeth,  are  by  attrition  kept 
to  a  certain  size;  if  "the  opposing  tooth  be  lost,  the  result  may  be 
an  enormous  growth,  which,  however,  speaking  strictly,  is  not  a  real 
h\  pertrojjhy. 

REGENERATION 

Loss  of  substance,  not  so  great  nor  affecting  so  vital  a  part  as  to 
rausc  death,  is  remedied  by  regeneration  o^  the  lost  part  or  by  com- 
pcnsatorv  overgrowth  an.l  increase  in  the  functions  of  other  parts. 
Si)iaking  generally,  one  finds  that  regeneration  is  slight  in  higher  forms, 


190 


PROGRKSSIVE  TISSUE  CHANGES 


and  indood  it  is  satV  to  say  tliat  aiiionR  tlic  lower  and  simpler  forms  of 
life  the  cai)a<ity  for  rc^'eiieratioii  is  tlie  fjreatest  and  most  complete. 
The  illustrations  of  tliis  statement  are  familiar,  and  need  not  he 
reiterated.  The  hydra  and  alHed  forms  will  re<,'enerate  in  any  direc- 
tion in  which  the  opposing  cells  have  luen  removed,  but  this  within 
hmits,  for  geotropism  is  a  factor.  In  a  tuhnhirian  tlie  head  will  Rrow 
only  upon  the  ui)i)er  end,  the  ''lot  only  njjon  tiie  lower  end.  This  is 
valuable  as  indicatinj?  the  jMUver  of  influences  external  to  the  l)ody, 
and  shows  us  that  the  capacity  of  the  cell  to  i)roIiferate  is  a  function 
of  its  relation  to  other  cells,  and  of  the  action  upon  it  of  certain  piiysical 
influences.  AVe  say  its  relation  to  other  cells;  for  it  lias  been  noted 
that  tiie  j)lanarian  (a  flat  worm)  head  under},'oes  i)erfect  rcfjencration 
only  when  the  ventral  nerve  gan<;lion  has  not  been  destroy  !.  A 
])arallel  instance  is  seen  in  some  crustaceans,  where,  if  an  eye  be 
removed,  there  dcveloi)s  in  its  jylace  not  a  new  eye  but  an  antenna-like 
or^an,  unless  tiie  f;an^dion  cells  connected  with  tlie  eye  have  been  left 
intact,  in  which  case  m  eye  is  redeveloped.  Thus  it  seems  that  while 
nerve  cells  do  not  initiate  the  regenerative  process,  they  yet  influence, 
or  even  control  the  ultimate  cell  relationships  and  functions.  Nor  is 
it  the  active  functioning  of  the  cells  that  initiates  the  regenerative 
process,  for  in  the  earliest  stages  of  a  regenerating  eye  (jr  limb  of  an 
arthroi)od    the  new  parts  arc  entirely  incapable  of  function. 

In  the  higher  vertebrates  and  in  man,  the  capacity  to  reproduce 
lost  parts  aii<l  organs  is  wholly  wanting.  We  can,  however,  recognize 
the  capacity  to  rc|)rodu(  c  lost  tissues,  l)ut  this  only  within  certain  limits. 

1.  //  ail  union  he  contitldrh/  rcminrd  or  (Icsfroiicd,  it  cannot  regenerate. 
If  t>nly  a  jiart  be  taken,  the  rest  may  proliferate  and  bring  about 
regeneration;  if  a  whole  bone  be  removed,  it  is  not  replaced,  but  if  the 
periosteum  be  left,  a  regeneration  may  occur. 

•_'.  The  hinlier  and  mure  specialized  the  tissue,  the  Jess  is  its  capaciti/  for 
rnjeucnitiou.  A  part  of  a  nerve  cell  or  a  fibre  may  grow  again  after 
destruction  but  not  the  wiiole  neurone. 

Tiic  muscles  regenerate,  but  imperfectly.  Xor  is  it  remarkable 
that  regeneration  in  the  higher  kinds  of  tissue  should  be  a  difficult 
matter,  because  not  one,  l)ut  several,  orders  of  cell  deveh)|)  side  b\ 
side,  and  the  more  rapidly  develoiiiiig  new-formed  connective  tissue,  for 
cxamiile,  is  ajjt  to  bring  ])ressiire  to  bear  upon  the  new  acini,  or  lobules, 
and  to  cause  their  atrophy.  The  salivary  glands  and  the  thyroid  regen- 
erate moderately  well  by  a  process  of  budding  from  the  duets,  but  mcst 
of  tlie  other  coini)lex  organs  and  glands  can  scarcely  be  said  to  regenerate. 

In  tlic  li\cr  it  is  to  be  noted  that  the  part  most  ready  to  proliferate 
is  the  l)ilc  duct,  and  this  is  (juite  in  accordance  with  our  knowledge,  for 
we  find  tiiat  wiicre  different  cells  of  tlic  same  order  are  differentiated 
to  varying  degrees  of  i)erfcctioii,  the  le>s  differentiated  arc  more  apt 
to  regenerate  than  tlie  more  differentiated;  in  an  ordinary  gland,  for 
cxaniplc.  the  cells  in  tii(>  neck  or  in  the  duct  are  more  likely  to  pro- 
liferate than  those  of  the  acinus. 


REGENERATION 


191 


3.  Tulnilc's  in  tlic  kidney,  and  lohnles  in  the  liver  of  the  adult  rewner- 
ate  only  to  the  extent  that  lost  cells  are  rei)laeed.     Onlv  in  the  verv 
young  are  there  indications  that  new  tubules  or  lobules  mav  be  formed 
llepencrntion  in  the  wore  miiiiMr  the  i/oiiiifier  the  aiiinidl. 

There  has  been  a  good  <lcal  of  discussion  as  to  why  re,i;enerated  tissues 
so  often  atrophy  in  a  comparatively  short  space  of  time.  The  reason 
IS,  probably,  that  where  tissues  of  widely  diHerent  decree  of  difl'erentia- 
tion  exist  side  by  side  in  the  same  organ,  the  less  diHereutiated  gain 
so  great  a  lead  over  the  more  differentiated  and  regenerate  so  much 
more  rapidly  that  active  pressnn-  is  brought  to  bear  upon  the  latter 
to  their  detriment. 

Regeneration  of  the  Various  Tissues  in  Man.-  Connective  Tissue.— 
II  hite  tibroiis  Connective  Tissue.  This  is  the  most  active  of  all  re-cn- 
. Tilting  tissues  in  the  body.  The  fibrous  connective-tissue  cell,  un.h.r 
stimulus,  swells,  becomes  larger,  gains  more  cvtoi)Iasm,  and  gives  off  a 
rather  round,  plump,  soft  cell,  which  shortly  becomes  s(.mewhat  more 
t.isi  orm-the  fibroblast.  There  has  been  cousi.lerable  discussion  as 
to  the  derivation  of  this  cell,  and  there  seems  no  reason  to  doubt  that 
It  arises  alike  from  the  endothelium  of  the  vascular  channel  and  the 
>iiI)portive  connective  tissue,  two  kinds  of  tissue  whose  close  similaritv 
vwn  wh()se  absolute  identity  we  have  previously  uphehl.  (Joing  farther' 
many  hold  that  the  plasma  cell  also  takes  part  in  regeneration. 

There  are  several  .liHerent  cells  found  wandering  in  the  tissues 
winch  Ma.ximow  includes  under  the  term  polyblast,  and  fV.llowing 
Ins  observations,  there  is  an  increasing  tendencv  to  believe  that  all 
■-iicli  cells,  having  a  round  or  oval  nucleus,  as  distinguished  from  those 
liiiving  a  i)artite  nucleus  (polynuclears  and  eosinophilcs)  mav  take 
p;irt  m  tissue  upbuilding. 

Elastic  Connective  Tissue.— Thvrc  is  no  (lou})t  that  elastic  tissue 
ngenerates.  It  is  to  be  found,  newborn,  in  areas  of  new  connective 
n^sue,  and  m  such  places  as  the  intima  of  arteries;  but  we  have  not 
>.t  settled  what  kind  of  tissue  gives  rise  to  it,  nor  do  wc  think  it  likelv 
t  lilt  Its  origin  is  different  from  that  of  the  white  comiective-tissu"e 
li  Tc.  i!  IS  to  be  kept  in  mind  that  elastin,  the  component  of  the 
'l.istic-tissiK  hbre,  is  a  relatively  inert  protein  differing  but  slightlv 
!'"iii  the  more  active  albumins  of  the  -upimrtive  cell. 

Fatty  Tissue.  — It  is  uncertain  whether  we  should  speak  of  the 
y  -.ncration  of  fatty  tissue,  because  wc  are  not  vet  certain  if  fatty 
'i -lie  IS  a  distinct  entity  or  is  a  modification  of  connective  tissue- 
re  IS  much  evidence  in  favor  of  the  belief  that  it  is  not  a  distinct 
'^  ne.  AMiat  is  the  fat  cell?  It  is  chiefly  considered  to  be  a  connec- 
ti  .-tissue  cell,  or  a  number  of  connective-tissue  cells,  which  have 
"'  tiphed  in  the  neighborhoo.l  of  a  capillary;  in  the  cvtof.lasm  of 
-:  li  cells  fat  droplets  appear,  fuse,  and  push  the  nucleiis'to  one  side 
';  !l  we  see  histologically,  the  huge  fat  droplet,  surrounded  bv 
t  '  <iH  incmi>rane,  which  shows  at  some  part  of  its  circumference 
""   ■i.itteued  nucleus,  representing  the  seal  in  a  signet  ring  looked  at 


192  PROaRESSlVE  TISSUE  CIIASCES 

from  the  broad  side.  Some  ^yX^l'^^^^^^^^^^^' 
smaller  cells,  and  in  places  where  t^f/f/;;,  f 'iy  ,,v'^^,f  the  difHculty 
times  see  a  nun.her  ot  closely  at,'prej^i.       ^.^^'^^  ^^^^  f,t  cell  as 

growth  IS  slow.     Un>  occurs  in  i\m  n        '  „,.,-,...,ti„„  direct  from  the 
(1)  perichondrial  regeneration,  and    (J)  regtn.r.itu.u 

aspect  of  the  perichondrium,  and  these  ^f^J^^^^'  iColdct.  which 
in  their  forms  of  r.gcneratum.     '^^»^^"J"  ;'^,,,,,,^.,  , ,.,,.,.  reniarkahl." 


REGENERATION 


193 


tlio  entire  process  of  growth;  all  these  forces  which  are  thus  seen  to 
Imilil  uj)  the  bone  in  the  first  i)lace,  take  part  in  regeneration  after 
injury  or  destruction. 

Periosteal  Regeneration-  X.-is  of  bone  denuded  of  their  periosteum 
have  been  seen  to  obtain  a  new  layer  by  continuity  from  the  adjacent 
P'  riosteum;  mere  stripping  of  the  periosteum  from  the  bone  does  not 
necessarily  render  the  bone  liable  to  necrosis.  When  periosteum  regen- 
erates, it  occurs  firmly  attached  to  the  bone,  and  separated  from  the 
n\erlying  coimective  tissue;  the  direction  of  the  fibres,  too,  suggests 
that  the  growth  is  from  the  periphery  of  the  area  destroyed. 

The  Jiegeneralinn  of  Meditlla.—lujuTy  to  the  marrow  cells  is  quickly 
followed  by  the  ii  ual  degenerative  changes,  which  quickly  give  place 
to  mitosis  and  proliferation;  equally  readily  the  connective  tissue 
around  the  capillaries  begins  its  proliferation  at  the  margin  of  the 
injury,  whence  fibroblasts  are  pushed  into  the  injured  area.  It  is 
remarkable,  however,  that  there  is  little  migration  of  leukocytes;  new 
(■aj)illaries  form  and  a  new  fibrillar  network  pervades  the  area  of 
injury,  in  the  meshes  of  which  are  the  constantly  increasing  yoimg 
marrow  cells.  Pieces  of  injured  bone  are  seen  surrounded  by  osteo- 
clastic giant  cells. 

The  Healing  of  Fractures.  —  It  is  scarcely  necessary  to  deal  here 
with  the  mode  of  repair  in  bone  because  this  is  so  fully  considered  in 
works  upon  surgery,  but  it  may  be  noted  that  considerable  variation 
in  the  process  occurs,  dei)ending  on  whether  the  apposition  is  good,  and 
tlie  nutrition  of  both  fragme.its  preserved.  The  more  perfect  the 
:il)positi()n,  the  quicker  is  the  repair;  the  greater  the  amount  of  riding 
of  one  fragment  upon  the  other,  the  greater  the  irritation,  the  exuda- 
I  i(  III  and  the  callus.  A  poor  blood  supply  will  mean  a  delayed  or  arrested 
union.    The  callus  forms  as  follows: 

(/()  Hemorrhage  and  exudation  around  the  fracture,  with  coagula- 
tion. 

(/))  Invasion  of  the  coagulum  by  cells — polynuclear  from  the  sur- 
ronnding  soft  tissues,  fibroblastic  from  the  periosteum  and  marrow. 

I')  Absorption  of  the  fibrin  and  replacement  of  the  clot  by  tissue 
fiiini  the  periosteum  and  medulla,  which 

iV/)  becomes  converted  into  cartilage,  a  step  that  may  be  lacking 
if  the  callus  is  small. 

(' )  Then  begins  the  process  of  laying  down  the  osteoid  tissue  with 
't'  pn-it  of  calcareous  salts  in  the  matrix,  either  with  or  without  the 
|r.  liniinary  intervention  of  cartilage,  the  subsequent  absorption  of  the 
-  nic  and  its  replacement  by  lamellar  bone.  In  the  lapse  of  time,  the 
'  M  (  ss  of  bone  is  removed,  and  the  callus  remains  just  suificiently  strong 
Tm  Mciire  stability  of  the  part. 

Regeneration  of  Lymphoid  Tissue.— The  specific  cell  of  lymphoid 
'-III'  is  the  lymphocyte,  which  is  constantly  regenerating,  and  the 
Mijiiortive  structure  is  made  up  of  the  comparatively  unspecialized 
1'  luhun,  which  we  have  indicated  as  the  most  readily  proliferated 


194  PRoanEssivE  tissue  changes 

of  all  tissues  New  Ivn.pl.  nodes  npp.ar  in  various  sifs  in  the  sub- 
;^^on;S  ttue  uhere  il.ey  have  n..t  '-"  J'-'^  >; -;'^-^- 
his  is  doubtless  .Ine  to  lyn.phoevtes  eounn^  ■'';-^.,  *^\  ^.^'^  £ 
as  regards  food  supi'ly,  to  their  ,.rolileration  ..r  pe  uips  to  a  su.u  en 
acSn  of   ..owtll  on  the  part  of   lyn.phat.e  1,>sue  that   has  been 

^""J*;^;:.;;!"^'  Our  ideas  of  the  U-nk.-eytes  ten.l  to  the  supposition,  tlu^t 
tl.^f  tm^^re.'    erate;  they  ari..  in  bon.  n.arrow  fron.  the  niyeh.cyte, 
t  n  e       a  le  then.s  .h  es  to  institute  any  process  ot   repro.luet.on, 
and  t  ei  enranee  in  nun.bers  apparently  ,rc-ater  tlum  v.sual  m 

?hc  bloo  not  aUvavs  or  necessarily  due  to  increased  rt1»roduet.on. 

but  iTv  be    lue  to  a  dilVcrent  .listribution  of  K.-koeytes  a.ready  u. 
lltZZ     The  production  of  ,.ew  leukocytes  .s  a  process  tha     |;oe^ 
on  coust'ant      throughout  life  under  physiolo.trical  stuuuh,  and  thus 
can  scarce  V  be  properlv  in.ludcd  au.on,  patholo;.u-al  regenerations. 
''Lgenerln  oi^Blood-vascular  Tissue.-    In  the  -'';>;;' '.^.f-.^, 
methods  bv  ^vhich  new  vascular  tissue  can  arise:    (1)  in  intraallular 
for  no.    of         ul  chann.ls,  by  which  cells  hoUow  out  and  ,ive  rise 
rheir  interior  to  blo..d  corpuscles,  the  spaces  later  luroni.ngeon- 
Ltel    (Ta  pn.eess  ..f  bud.liu,.  in  which  certain  endothelial  cells  of 
eaSh  n    wall     pve  <.tf  Ion,  protoplasmic-  pn.crsses,  withou     nude,, 
S-    connect  one  capillary  with  another;  these  processes  hollcm  out 
and     1        passes  into  aid  thn.i.t:!,  the  process;  ultunately  nntos, 
Jlu   oi.'inn    end..theHal  cell  occurs  an.l  the  new  nucleus  Passes  in 
t  wail  of  the  tube    ^vh..n;Ws  the  <.^^ 

n'^i;ron:ti::i:  :tl  it'-rb;.;:.  -llready  ..escribed  in  the  process  of 
vascularization  of  granulation  tissue  (see  p.  \-M. 

Regeneration  of  the  Mother  Cells  of  Red-blood  Corpuscles.     1  he  re  - 
l,l,^T™cles    arise    from    muleated.    lH.no,lobin-.-on  ami.g   c  1  s 
e  b  r  marrow,  the  hematoblasts.     Whether  these  hemafblasts 
"n-    bl    t     a  ise  from  prcformc.l  hciuatoblast>     a  true  re,enerat,on-- 
is  d  ibtt^ul-  it  is  more  likely  that,  un.lcr  the  stimulus  ot  neec.Mt> 
S.    e   n^'be  an  h.creascd  produ.tion  of  hematoblasts  tnnnj.s  d  tU. 
entiated  "mother  <rlls"  in  the  marn.w;  as  asam.  more  rarel>,  in  the 
.picen  and.  it  may  be.  the  lymph  or  hem..lymph  no.les. 
^Regeneration  of  EpitheUum.     Kpithehum  can   re,.nerate    and  m  v 
epitheUum  arises  onl>    from  pre-exi^teiit  ^'l»tl-{'>'  '  ;         ^  /^^^^^^^^^ 
.icention  in  which  epithelium  appear,  in  the  midst  o   -ranulation  tiss  u 
\^^M  bv  aeJidental  trans,.lantation  of  I'P" -'•!'"';,  ^    '^^ , 
ncii  tcHce  ..f  epithelial  elements  deep  down,  as  in  the  depths  of  a  lia 
fol  de      \notler  apparent  exception  oc.-urs  in  ,d,omata-^new  gnnvtl 
Sfmm     he  supportive  tissue  of  the  nervous  system-  in  wh    h 
'c^^    coi       to  be  lined   by  a  regular  layer  of   rather  c-..lumnar  cells, 
U  is  no     rr  ain  that  this  is  tnu-  epithelium,  f..r  one  searches  m    am 
orU^nnent  membrau...  the  c.l!.  lying  do.-ly  upon  tl-  -  inml^j 
ndividuals  of  the  next  laxcr.     Were  it  proved,  however,  to  bt  true 


r-  y'*r..^:ii^  mamemt:' 


REGENERATION 


195 


I'IG.    HI 


^^■:<- 


:i-itli(>liiim,  it  would  not  jtovc  the  origin  of  cells  of  one  order  from 
Inrehciirs  of  another  order,  for  the  ^va  is  of  epiMastic  origin. 

The  epitheliinn,   like  the  endothelium  of  bloodvessels  and  serous 
•  Mvities,  ean  regenerate  compl.^tely.     If  the  epith.lium  of  the  skin  he 
im.ken,  the  lower  layers  (not  the  keratiniz-d  cells,  which  are  inert 
l-ccanse    deg(>n«Tated)    become    active,    and    these    cell?,    her  .minp 
rionpted,  slide  over  one  another,  still  preserving  protoplasmic  con- 
nection, until  they  form  a  soinev  hat  flat  skin  over  the  demided  surface 
the  new  skin  forming  at  the  expense  of  the  old,  whicii  can  be  seen 
f.  he  thinner  than  normal  at  ilie  edge  o.'  the  injurv.    INIitosis  quicklv 
I'lgiiis  in  these  flattened  cells.    There 
i-  as  yet  no  basement  membrane,  but 
this  is  soon  supplied,  evidently  by 
tlie  fusion  of  fibrils  from  the  uiider- 
i>iiig  connective  tissue.     I'ntil  this 
I'liniis  tiiere  is  free  passage  of  leii:.o- 
iMcs   through   the   superficial  cells, 
and  cxen  ph.igocytosi.s  of  leukocytes 
l>>    file  ei)ith(iiiim. 

Ihiirs,  swt-at,  and  sebaceous  glamls 
may  grow  again  if  their  deeper  parts 
lia\c  lint  been  destroyed,  and  it  is 
■^t(•^(•■^tillgto  note  that  in  such  cases 
iImtc  is  sometimes  .i  downward 
-inwth  of  the  superficial  epithelium 
t'  meet  them,  an  observation  that 
-iiuiicsts  that  tissues  of  the  same 
iianirc  iiave  a  reciprocal  attraction 
i"i  nn('  another.  If  the  root  bed  of 
'ill'  liair  be  destroyed  there  is  no 
n -cneratioii;  and  the  same  is  true 
"I  the  nail  bed  in  the  fingers,  although 
tiii^  extends  l)ack  farther  than  is  commonly  supposed,  and  a  portion 
"j  It  being  left  accounts  for  the  appearance  of  a  nai:  after  a  terminal 
I'lialaiix  has  been  removed.  This  can  scarcely  account  for  the  appear- 
i    '  <■  .,t  a  new  nail- or  an  attempt  at  such- when  two  phalanges  ha\e 

<n  removed.     Here  we  are  compelled  to  admit  that  it  .seems  as  if 
-u   conditions  had  stimulated  a  metaplasia— a  change  of  nature  of 

I'-     of  the  ordinarv  skin  to  a  nail-producing  matrix. 

Regeneration  of  Mucous  Membrane.— The  process  described  for  the 
lirmis  IS  foiiiKl  to  exist  in  the  mucous  membranes,  to  the  extent 

t  (•(■lis  at  the  edge  of  an  ulcerated  area  mav  lose  their  cilia,  become 

"'I'-l  iind  ultimately  flattened  to  caver  the  denuded  surface    am! 

'^;i  ^iiuple  gland  follicles,  like  those  of  Lieberkiihn,  are  reproduced. 

I  Ih'  ;\teiisi\(>  regeneration  necessary  in  the  uterus  after  menstruation, 

•-  '■-'•r  t:w  i>!;ieriital  site  after  purturilion,  is  said  to  be  assisted  bv 
I'-Tsistence  of  the  remains  of  the  deeper  portions  of  mucous  glands. 


"rsi'iiilii-epithfliiiiii."  or  si'coiulary  cpithc- 
liuiii  without  busiinent  mpmbranc  lining  a 
cyst  in  a  glioma,  formed  by  moditiiatioii  of 
the  suiKTlicial  inyc-r  of  glioma  fells.     (Saxer.) 


t^m-rt- 


PROGRESSIVE  TISSUE  CHANGES 


[if 
m 


196 

«  w«j«th«Umii  —In  r  wav  similar  to  that  seen  in  epi- 

Regeneration  «*, ^'^''^f  ^^^  "mI  of  "translation  and  proliferation 

thelium,  endothelium  b>   a  "f '^'^     '\  \     ^i,^;,,  „r  tin-  cells  of  a 

quiekly  covers  over  ^  demuled  a     v    c   en  hbrn^   ^^  ^^^^^^^^  ^^^  .^ 

new  growth  t'';"^!^'""*^'^  ^I^'.^t  H^"-  ^"^'^""^  ^'''''  ^'""  '^-^' 
The  view  usually  acceptc^d   s. hat  m  ^^^^^^  ^^^^^.^^ 

existing  superficial  ,'^"[''f  ^^'T'       ^fiSalts  and  connective  tissue, 
existing  between  endotheha  '^;"^,.'^'";^7;^^^^^^^^^  area  may  arise 

V::trZ:^tZ^^  as  endothelium  has 

l:;;;S:.t5^^Htto,n..er^n^^^^^^^  ,,  ,  , 

Regeneration  01  G^^d.  \f\  [J,  structure,  such  as  the 
regeneration.  1  u  »'''";'  /'^'tj,,  ^  uterine  and  salivary  glands, 
Lieberkuhnian  follicles  of  the  »"t^f  "^  '"^      complex  gl?nds  the  ducts 

ao  present  --^^^-^^^l^^'^^^^  ^'"^  ^'^^  °^^'"^"; 
are  mainly  or  entire  >  the  source  j     ,^„d,  have   a  great 

Se'rrXrt  r  „  oTthe'»  co„,pa„M,.  ..e„e..io„  ..  .he 

supportive  structures  which  e«'"P'^'' *j;Tin  the  laboratory  by  chloro- 
JTver.-Where,  as  in  poisonmg  ^";"™'/;he  fiver  cdbS  the  centre 
form,  there  is  induced  a  state  ot  "^"^'"^  .  "  ^J''^'^^^^^^^^^  of 

of  a  lobule,  regeneration  «-'-,^^ '.^^^     i^^     ith  ^^^^^^^  g-wth 

the  more  peripheral  cells, ''"'/  ^  ^^.4",;'  ^^e  cells  have  disappeared,  so 
come  to  occupy  th^^^P»/'^^^;";^^X'eNm^^^  comy^lete  regeneration, 
that  in  the  course  "^  ^/T  ^  .^^^ V'  ^'^  Sgone  n-  rosis  from  one  or 
So  also,  where  ^•^^^P'^^*'^^^"^"'^^ '^^^  V'^^^^^^  of  new  buds  or 

other  cause,  there  has  been  •^^-f^-'^^j^JM^^^^^        the  framework  of 

S  r£rr;Sl:t  rr^-^  at  most,  the  remaining 
liver  tissue  exhibits  some  hyP^'-t'-^Phy-         -.^^^^^^  ^av  be  rerlothed 

i,„,«tect  an,l  .  .h»"t  'l"f  ■™„,''l!V.3il.d  tubules  appear 
injuml,  but  ,„  *«JI'Sev  it  n,  to  contain  more  than  the  nonn.l 
:°ES'^:;p:  i-.l'S/'netti.e  corte.  a,e  »nsi„eted  to  be  the 

of  the  view  that  regeneration  d"^^  "^^  *X  thrn^^^^  mueoseeand 

..rr.Trrr^ii'-^^^p-ri-i-o-,  «„..  >« »... 

animals,  new  fibres  have  been  seen  to  form. 


REGENERATION 


m 


striated  Muscle.-  If  the  substance  of  a  muscle  fibre  be  partly  de- 
stroyed but  the  sarcoleama  sheath  left,  a  complete  regeneration  may 
.Kcur;  but  where  there  is  actual  injury  wrought  to  the  fibres,  these 
rontract  away  from  one  another,  and  the  regeneration  of  the  inter- 
l.l.rillar  connective  tissue  tends  to  check  the  regeneration  of  the  injure<l 
imiscle.  let  m  any  given  case  some  fibres  will  succeed  in  preserving 
t he  sarcolemma  and  other  not.  When  it  is  preserved,  some  nuclei 
^tui  remain  with  cytoplasm  around  them,  and  these  gradually  multiply 

PlO.  62 


D 


su,-,e,,ve  stages  m  the  regeneration  of  voluntarj-  muscle:  A.  forn.ation  of  bud  of  cvtopIaBn.  with 
I .-.  of  strmtjnn  and  mult.phca.ion  of  muscle  nuclei;  B.  the  nuclei  acquire  cytoplasn.ic    e^  one.  anS 

I  -.  m,nuclea  e  and  multinucleate,  separate  fron.  the  hud  (sarcoblas.s) ;  a  unalter  ,i  en7of  n'uscle 
l.l.r,  ;  K  .arcoblas.s;  c,  multinuclear  sarcoblas..,,  one  nucleus  at  d  showing  mitosis    C   enrlv  ...         r 

;:;::  "T : /onr;  r"""-'?''  r  -'*"''•'"'' "'"«""''''""  "'"■"-"■  beco-i^^fu::^  wuh  tht  gL: 


■"1.1  are  surrounded  by  constantly  increasing  cytoplasm,  lying  aggre- 
^.if.  <l  in  clumps;  from  such  a  clump  individual  mono-  or  multinuclear 


I'l 


Millet 


..^~,  ..„„.  .„^„  „  ,^.,.11.,,  ujuiviuuai  mono-  or  multinuclear 
1^  M'F'arate  themselves,  and  absorbing  the  remains  of  the  old  striated 
i.^taiue  they  attach  themselves  to  one  another  or  to  the  undamaged 
P:>rt  of  the  muscle,  and  gradually  become  first  longitudinally  then 
transversely  striated;  the  old  sarcolemma  sheath  ....mes  absorbed 
•'  -  i  new  one  appears.  When  the  sarcolemma  is  ruptured,  as  in  a 
cu  or  a  laceration,  the  capillaries  are  also  ruptured  and  the  picture 


198 


rROGRF.SSIVE  TISSl'h:  CHASCES 


III 


% 


..f.w..,l      Tl...  riii)ture«l  fibres  contraot  into  clumps, 

eSt;  Jll^munlHT  of  nudoi  hecon..s  ro.hu.e.l,  the  eyto,.las,u  .n.-reuM.. 

'^C:;:;S:'of '  N:^^^si;r''i;^o,Ua.  -TI.  neuroglial  ti^ue 
Is  pSSat  t  is  a  eounective  tissue  au.l  yet  s  of  epiLlastw  on«.u 
;:];;;tfaet  ..  eloseU-  rolatea  to  „en.  ^^^  r.^-^l/'lt^-eS 
f  u't^rSl^gSa'E:::^.  u  tl^  llJXre  is  no  .louht  ti.at  .iial 
S  ^euetra  ana  Su-v^^r^^  able  to  for.u  not  only  tunu.rs  hut  rep  aee- 
m^t^^'isln  L  cas.  of  loss  of  ,».rve  eells.  ^<7-  V^^  fm. 'Ion 
thouKht  thev  have  seen  them  RivinR  rise  to  eel  Is  wh.di  take  the  urn  t 
of  mivl.  cells,  but  this  can  be  deternjine.l  only  u.  the  very  >oun,  an.l 
even  then  seems  to  oiler  ground  for  doubt. 

Nem  CeUs-It  mav  be  definitely  state.1  that  the  nc-rye-eell  bodx 

a  preSs?rng  axis  c>'inder,  and  then  only  when  u.  connection  ^Mth  a 

'"S?nerve1bre  ..r  its  axis  cvlin.ler  be  severed  there  is  .legeneration 

^|;:.:SLd^erian degeneration- distalw^n^ltl...^ 

axis  evlinder,  and   on  the  proxunal   side,  as  ''^V     fl,!t   itthe    esult 

nt  tlie  iierve-ocU  bodv,  ami  tlic  pruxinial  portiun  iil  the  aMmi.     leu  i 
: Lt„  ;ra  ■  ....,  ■,«  *!,»  dU,.!  ,»«  .,t  a  <t.vuM  nerve,  pr„u.W  ( 
tV,..t  iho  n'lrent  cell  be    ntact  and  undaniaj;ed ;  (2)  that  tlit  organ  » 
'pa       UK^rf  "..t  atrophied  or  degenerated   a„d  (:»  t  ,a.  a  e,„,  r. 
1  *  uh.r.l-  tJiP  tr-H'k  of  the  reeeneratmg  fibres.     \Mtn  rtgara  w 

i;rthw'  IcS  c  S^i^s  an  inlperfect  ^generation  n.ay  in  these 
the  t'"["^  ;  *  ^'  ';\  ,  ,,  .^^  i,  ,^.en  in  the  so-called  amputation  neuroma. 
"r''l  vv  rm  a  the  end  o  a  dividcl  nerve,  i..  which  the  gnnnng 
:;:^e   SSls   1™  :^>e   t4ted   through    the  fibrous   connect.ve-t.ssue 

"^i^^m  i>f  mdi^irt^::^^':^^^    --^  --^'^v  -'-"i-r 

Ncry  "^'^^V    ;.,-'.      .j,„,  ,n„ltiplvinj;  close  underneath  the  shear i.. 
''lf"rlSre  be  hJuJed  Jhe  ^is  iiindtr  stains  imperfectly,  becomes 


.^■n-  mf 


GRAFTING  OR  THANSl'LASTATIOX 


199 


fihrilliitcl  and  (lisitit(Kniti-<l.  The  myelin  slicath  divides  up  into 
irr(j,Milar  masses.  Now  fli.-  miclei  of  the  slieatli  of  Sduvami  begin 
to  proliferate;  tliey  pass  hetween  the  masses  of  nivelin  and  pick  up 
from  it  their  eytoi)hism.  Some  of  these  new  cells  degenerate  and  die, 
and  others  become  cloii<;ated  and  spin.lle-sliapcd,  and  jjive  rise  to 
the  new  sheath  of  Schwann  and  the  myelin.  The  axis  cylinder  mean- 
time i)rolonj,'ates  from  tlie  central  end  of  the  damaged  I'lerve  and  has 
at  its  tip  a  nodular  mass  of  i)rotoplasm,  which  is  apparently  motile 
and  creeps  ahead,  laying  down  tlic  axis  cylinder  like  a  telegraph  line 
liehmd  it,  its  general  course  being  along  the  lines  of  the  old  sheaths  of 
Schwann. 

Regeneration  after  Section.  Regeneration  under  tliese  circumstances 
1^  brought  about  in  the  same  way,  but  the  new  spindle-shaped  cells 
iind  ..le  new  end  of  the  axis  cylinder  being  no  longer  guided  by  a  rem- 
nant of  the  original  sheath  may  take  a  tortU(»us  course,  especially  if 
tlie  two  ends  of  the  nerve  are  widely  apart.  Time  is  lost  in  the  process 
nil  this  account  and  ((uickcr  regeneration  is  obtained  if  a  guide  of 
><.ine  sort  be  placed  between  the  two  ends;  sudi  a  guide  may  be  a 
liollow  piece  of  bone  or  a  bundle  of  catgut  threads.  In  spite  of" a  con- 
Mderabie  distance  between  thf^  two  ends  and  the  piling  up  of  .scar  ti.ssue 
a>  an  obstacle  \ery  remarkable  regenerati(.n  of  ixripheral  nerves  has 
M.curre<l,  gaps  of  10  and  12  cm.  in  the  dog  having  been  bridged,  the 
I'locess  requiring  a  couple  of  years. 

GRAFTING    OR    TRANSPLANTATION 

Transplantation  means  the  inserting  of  living  tissue  into  living  tissues 
and  may  be  autoijla.stir,  that  is,  when  individuals'  own  tissues  are 
i:ratted  on  themselves,  isopl(i,itic,  where  the  tissue  of  another  animal  of 
the  same  species  is  used,  or  lictcroplastic,  with  tissues  of  another  species. 
Implantation,  while  a  similar  process,  dues  not  demand  the  use  of  a  living 
ti-ue  as  a  graft. 

The  remarkable  results  obtained  by  grafting  in  arl)oriculture  and 
i;ar(lemng  are  familiar,  and  low  forms  of  animals  >Iiow  a  great  readi- 
ng- for  growth  if  they  are  grafted;  with  the  w aim-blooded  animals, 
n-uevcr,  this  is  by  no  means  the  ca.sc.  One  niav  make  a  general  state- 
iiM  lit  to  the  efi'ect  that  immediately  after  grafting  the  tissue  inserted 
n.ay  gn)w,  yet  in  a  comi)aratively  short  time  die  planted  tissue  becomes 
ii'-orbcd  and  a  cicatrix  alone  may  remain,  although  sometimes  the 
uritt  forms  a  framework  upon  which  the  regenerated  tissue  fills  in  the 
a:- 11.  Even  in  this  short  i)criod  of  growth  after  transplantation  it  is 
"Mm  notable  that  the  proliferation  of  the  transjjlanted  tissue  occurs 
ilnMiigh  g.  derations  of  cells  that  gradually  become  less  and  less  specific. 
1  Mrcsserl  in  other  words,  there  is  at  once  a  reversion  in  the  type  of 
'! '  '(lis  transi)lanted.  Considering  this  fact  one  would  naturallv  con- 
'  ;;  that  if  embryonic  vegetative  tissues  were  taken  in  the  first  place, 
t!    implantation  would  be  much  more  likely  to  succeed,  and  such  is 


v^ijqrjw-r-^-^^ 


200 


PROGRESSIVE  TISSUE  CHANCES 


\ii 


the  case.    But  even  in  these  oases,  as  where  portions  of  ^^h'^k  ^'J' 

"iSX  the  t™"pla".o<l  «lana»  l'ea,..un8  cnUrscJ  ami  »-c-tmg 
"'^\:tXC"«o„  ,.,  the  ..-,  h„,  n,et  wi*  almos^"^-' - 
not  in  a  I»-«":,  i;;,';  "i^  !^^^^^^^^^  sum^ctal  i„  bavins 

tljc  f  >;?'"  Pf  »' *',  ?,"  MalSan  lav.;  are  ,»n  to  Aow  mitosi« 

K^;,ysp"":,itt.inla^ent.e„.a.^^^^ 

j^,,  ,.av™«  actually  a^^^^^^ 

ESiS€b?:t"'^rE;;:T:;e^tJj3^ 


ORAFTINO  OR  TRANSPLANTATION 


•^01 


hut  subsectuently  will  bocomo  piRtiiented.  This  may  mean  that  there 
is  a  siihscquftit  r«i»liRfmt'nt  of  tlie  graft,  piecfmeft'i,  by  cells  derived 
from  the  orijriiial  epithtlinm  c.f  tlie  host,  that  is,  that  the  permaiieiur 
of  the  graft  is  only  ajjpareiit  and  not  real.  In  support  of  tliis  it  may 
l)f  said  that  in  no  j-«se  is  the  skin  of  another  speeies  successfully  jcrufted 
on  man;  nevertheless,  the  mere  presence  of  an  animal  graft  seems  to 
stimulate  the  skin  cells  of  man,  causing  them  to  spread  more  rapidix 
than  usual  over  the  denuded  surface.  This  may  be  another  instance 
of  that  i)henomenon  to  which  we  have  previously  referre* I,  namelv ,  that 
cells  of  like  order  attract  one  another;  that  is,  that  the  presence  of 
epithelial  cells  in  the  centre  of  a  denuded  area  by  homotropism  attract 
the  epith«'lial  cells  of  the  host  around  the  edge  of  the  denudcfl  area. 
It  may  be  that  the  diffused  prwlucts  of  activity  of  the  grafte<l  cells  act 
like  allantoin  (Macalister)  as  cell  proliferanis  or  aiixetics,  Ross  having 
shown  that  the  dissociation  products  of  proteins  stimulate  cell  prolifer- 
ation. 

Transplantation  of  Mucous  and  Serous  Membranes.—The  mucous 
membranes  are  quite  as  apt  as  the  skin  in  transplantation,  and  the 
mucous  membranes  of  the  lips  and  of  the  mouth  have  been  used  to 
supply  denuded  areas  on  the  eyelid.  Similarly  autoplastic  grafts  of 
the  great  omentum  have  been  emj)Ioyed  successfully  to  cover  peritoneal 
wounds  as  also,  recently,  of  fascia  and  tendons. 

Transplantation  of  Teeth  and  Bone.— Transplantation  of  tt.  th  and 
of  bone  ijroperly  speaking  (1»h's  not  occur,  being  really  implantation. 
It  is  of  interest  that  the  Romans  understood  the  implantation  of 
Jirtificial  teeth,  and  for  many  centuries  in  India  teeth  have  been  taken 
from  one  person  and  implanted  in  the  jaw  of  another.  The  results 
are  equally  good,  whether  the  tooth  be  newly  drawn  or  one  in  which 
the  i)ulp  has  been  removed,  or  one  that  has  been  out  of  the  bo<ly  for 
many  years;  in  other  words,  it  is  not  an  organic  union,  but  rather  that 
vessels,  nerves,  osteoblasts,  etc.,  jjcnetrate  into  the  pulp  cavity,  the 
tooth  i)roper  continuing  to  be  an  inert  substance,  which  in  soine  cases 
l)ceomes  absorbed,  with  failure  of  the  procedure.  Much  tl  e  same 
>t,ite  of  affairs  is  found  in  the  implantation  of  bone,  sterilized  bone  or 
ii( calcified  bone;  such  l)one,  like  any  other  porous  material,  is  merely 
M  framework  which  fulfils  the  functions  that  the  fibrin  fulfils  in  the 
I'liKid  clot  with  tile  additional  quality  of  rigidity  and  consequent  pre- 
ir\  ation  of  the  contour  of  the  part. 

Transplantation  of  Periosteum  and  Perichondrium.— Osteoplastic 
traiisi)laiitation  of  these  is  very  successful,  especially  if  the  periosteum 
lie  retransplanted  upon  an  old  bone,  or  into  an  area  where  bone  has 
•  xisted.  Even  isoplastic  transplantation  may  be  successful,  but  it 
i>  notable  that  in  any  experiment  a  good  many  of  the  periosteal  oells 
'iia,\  (lie,  the  burilen  of  proliferation  remaining  upon  those  that  survive. 
riie  bone  marrow  lends  itself  perfectly  well  to  autoplastic  transplan- 
i.ition,  giving  rise  in  its  new  site  {e.  g.,  experimentally,  the  anterior 
<  liamber  of  the  eye  or  the  abdomen)  to  true  bone. 


In 


2„2  I'Ronnnssivh:  rissvt:  ciiasges 

"  iran.pUnUtion  of  V.s..ls.  ,•;«  ^W  Ut  f.^^  y;;^  ^it.;  i;^.- 

short    leM,tl.s   ..f    art.m.s   or    v.....    n  ^       \     ,„  '  ,,,,r,   ,1.,. 

otlKT  an»-iit:..  NMh"  /  "  '  "^-i  ,  ,„.,,,  ,„.r,Uteut  vitality  ami 
..(uration  has  lu-eii  'V'*''1'^'^^'^'.  ,  ;,  '  .1  iM.rtu.ns  of  tl»-  auto- 
,:,,.  ,rovvtl,  ..f  the  .ntro.hur.l  »';;";^  ,';;/;;   .*X,w  prom.un 

wiy.anlr\  ol  »  arrti  m  u«  i"'     i  .,    ,.  itli  ^iii-c«'ss  hut  fvni  orpins 

Not  only  ha.  la-  transplant.;.'  tn.h  -[;;;;;      'i'Vir'^ular  an^to- 
that  have-  iK-en  pn-sorvnl  tor  '';=''>'  'J    ^f'.^,  that  snc.rss  has 

METAPLASIA   AND   HETEROPLASIA 

IS  an  a.lapta  ion  on  tlu  part  oi  (   n  ...-ucrsion  <.f  or.h- 

a  c.on>tant  phvMo  ..Kual  I''••'^•^•7^"^  ?;    '^^  .        ;'^\,,..  transformation 
Han   .on.a..t.v..-t.s.u-  "-l';;- ';;   ^^  ;    ,r  D.^into  hony  .••■lis  an.l 

f"'t  t '■' Va  L;:i:.^  >  ''-''^^  <-tain  ri.i.l  la..;  epithelial 
hoi.y  tisMU  .    \  tt  "'y-'  "•   ,'•  ,       ,.  „f  ..pithi'lial  tissue,  nieso- 

tissue  can  he  .-onverte.l  onl>  mtu  otlu  ^^  ,  ,  '  ;  Kpitheliuin  an.! 
,,,as,ie  ti»n.-  ..nly  .nt.>  other  f..nn.  »^.;-^'^^.  J  '  i,.t,,  ,„„..  or 
.lan.l  cells  tor  eNa.nple,  can  ^^^']\''^^^^^Zn  .A  on.  U.vm  .>i 
cartilage,  or  vice  ver.a;  an.l  j^''';  ',,';,  .''^;'"t.e  ^aps  ar.-  hri.l,.-.l. 

^"'••^'''■'''"" '''\ "'u; r^ hn,; : :;;t  .  i-u  i-  ri".- 1.,  ......ipiex 

"r  Y  ""'tlW      r  e     ;   ;.ati.>n  of  hair  roots.     Fihr.>us  .•....- 

!;l:;:;t  ;^i  i:.!!  ;.-;  ..een  ....  t..  ..han.e  into  nnisele,  str.ate.l  or 
non-striatcl.  . .  . ,     ren.lere.1  function- 


Ifflf^ 


METAPLASIA  ASD  IIKTKROPLASIA 


2(Ki 


(1)  tliiit  tin-  hoiH'  foriiintioii  is  dur  to  tniMliticd  function  iid  nutrition 
of  ctTtain  clioroidal  (•••lis;  tln'so  (tIIs  Imvi-  normally  a  drli.  itc  fnnrtion 
conticctni  with  tlio  n.  tivinj;  of  li>;|it  Uy  tlic  ryo;  this  function  '  "itif; 
intt'rru|itt'(|,  tin-  vascularity  (»f  the  choroid  is  in<Mlific(l  and  certain  of 
the  choroidal  <clls  >;ivc  tlicnisclvrs  omt  to  the  prcMluction  of  hone; 
i'2)  that  in  the  process  of  formation  of  the  eye  u  few  cells  destined  to 
form  hone,  lieinj;  accidentally  carried  into  the  eye,  remain  latent  so 
loriK  as  the  eye  performs  its  proper  functions,  becoming  active  when 
these  functions  are  interfered  with;  (.'{)  hone-forminR  cells  arc  carried 
to  the  part  l>y  the  blood.  The  rcinarkHblc  fre(|ueiicy  with  which  this 
bone  formation  wcurs  in  tin-  choroid  of  eyes  which  have  been  rendered 
useless  by  injury  is  strangely  op|>osed  to  the  two  latter  hypotheses. 

Hefore  discussing  metaplasia  specifically,  it  is  necessary  to  separate 
one  or  two  conditions  which  arc  not  true  metaplasia,  but  which  might 
be  confounded  with  it.  The  first  of  these  is  heterotopia,  which  may  be 
congenital  or  acquired  and  consists  of  the  abnormal  snaring  of  cells  of  an 
wrgan  from  the  organ  proi)er,  and  their  siibse(|uent  growth  in  another 
place.  Kxamplcs  of  the  congenital  form  are  the  various  cell  rents  of 
Cohnhciin,  aberrant  adrenals  and  accessory  spleens;  examples  of  the 
;i((|uired  forms  are  periosteal  and  bony  growths  from  displaced  perios- 
tiuni.  It  is  to  be  noted  that  in  none  of  these  cases  is  there  tissue 
transformation,  for  the  tissue  continues  to  grov  along  the  ordinary 
lines;  further,  one  sees  the  same  process  in  the  invasion  of  one  tissue 
into  the  territory  of  another,  in  such  a  case  as  where,  after  tracheotomy, 
tiie  epidermis  may  not  only  cover  tlu;  wound  but  grow  some  little 
distance  into  the  trachea. 

Heteroplasia.  -This  is  the  condition  in  whicli  we  find  in  the  middle 
of  the  (esophagus  normally  lined  by  squamous  epithelium,  islands  of 
cohmmar  epithelium  like  that  of  the  stomach.  No  -Mnvcrsion  has 
occurred  from  one  ty|)e  of  ci)ithelium  into  th(>  other,  but  lere  is  merely 
ii  persistence  of  niisplac-d  and  ordained  tissue.  The  same  explanation 
1m 'Ids  for  the  occasionu'  islamls  of  squamous  epithelium  found  in  the 
n  spiratory  passages,  and  the  stomach,  without  any  evidence  of  past 
iiidanimation  which  might  accoimt  for  the  change. 

Anaplasia  or  Reversionary  Atronhy  ("Undiflerentiation").— To  be 

•  listinguished  from  metaplasia  is  tne  loss  of  diflerential  characters  by 

nils  which  h.'ve  become  subject  to  abnormal  conditions,  for  example, 

the  simplification  of  the  tubular  cells  of  the  kidney  in  nephritis,  or  the 

ubical  form  of  the  lining  cells  of  the  pulmonary  alveoli  in  interstitial 

|'iieu...oiiia.     The  same  jirocess  is  illustrated  by  the  development  of 

!iHK(iid  tissue  in  the  adult  body,  for  mucoid  tissue  developmentally 

;-  iiii  intermediate  stage  in  the  growth  of  another  mesoblastic  tissue. 

A  similar  process  is  the  morf)li(>logical  cha..,;e  of  cells  due  to  mechanical 

"  tion,  c.  .y.,  the  flattening  of  a  cubio]  or  cylindrical  epithelium  in  a 

:  -t  on  account  of  the  pressure  of  ito  contents.    Af    n  we  must  not 

•iiftiiuid   with  true  metaplasia  the  ditferentiation  of  a  tissue  under 

'  i'ldified  environment  without  any  change  in  the  function,  as  occurs, 


F.'-i--a-,^^<-'-. 


204 


PROGRESSIVE  TISSUE  CHANGES 


m 


for  exiiniplr,  in  the  coniification  of  the  rpitlu'liuin  of  the  prolapsed 
vagina.  Metaplasia,  in  oi)p()sition  to  this,  comprise  hoth  a  inori)ho- 
lo;;ieal  ami  a  functional  ehanfje. 

Epithelial  Metaplasia.  The  nnicous  nienihrane  of  the  uterus  is  a 
coluuiiiar  epithelium;  if  the  or^'an  he  everted  so  that  it  projects  from 
the  vagina,  its  muco'^a  becomes  smooth  and  dry,  and  in  place  of  the 
columnar  there  is  a  stratified  squamous  einthelium  with  horny  change 
of  the  external  laxers.  Here,  it  will  ho  observed,  there  is  a  change  of 
function  as  well  as  of  structure.  In  the  bladder  we  find  changes  of  two 
sorts;  normally  it  is  lined  by  polygonal  epithelium  in  several  layers. 
We  may  find  over  an  enlarged  prostate,  as  a  result  of  inflammation, 
areas  of  typical  squamous  epiderm,  with  prickle  cells,  or,  on  the  other 
hand,  we  may  find  jjapillomas  de\cloped  with  epithelium  that  is  now 
distinctly  columnar. 

Fill.  03 


Stiiges  in  Uie  nielapliistic  r<>gcni>r;ition  or  furrnnlion  of  u  new  Ions  from  the  iria,  'n  the  larval 
newt:  1,  ed^e  of  iris  lincominK  swollen,  2,  :!,  1,  progrosaive  overgrowth  of  the  edge;  5.  separation 
of  the  hypertrophicd  in;i»3  of  cells  to  form  the  len.i.     (.Kischcl.) 


In  cases  of  ecto])ia  vesica-  simpli'  glandular  crypts  may  form  from 
what  was  a  ■.!  any  layered  epithelium.  Kveii  more  remarkable  is  the 
metaplasia  observed  in  the  regeneration  of  the  lens.  In  the  larval  newt, 
if  the  lens  be  extirpated,  a  new  lens  may  be  ileveloped  from  the  iris,  as 
will  be  readil.N-  understood  from  Fig.  (')'■'>.  This  is  not  very  remarkable 
when  we  reineiiiber  tiiat  the  normal  lens  and  the  iris  though  differently 
formed  are  both  epii)lastic. 

Mesoblastic  Metaplasia.  Here  may  be  seen  the  metaplastic  forma- 
tion of  bone  from  cartilage,  as  occurs  in  the  tracheal  cartilages  in  advanc- 
ing age,  the  one  tissue  being  merely  converted  into  the  other.  A  similar 
process  is  the  replacement  of  cartilage  by  bone  in  the  callus  of  a  fracture. 
A  more  striking  exanii)le  is  the  forniation  of  bone  by  metai)lasia  of  con- 
nrclive  tissue  (Fig.  (m),  as  occurs  in  the  formation  of  masses  of  true  bone 
in  the  lung,  or  of  plates  of  true  bone  ir  old  pleural  and  pericardial 


=1^.. 


-v^i. 


n:.' 


METAPLASIA  AND  HRTEROPLASIA 


205 


adhesions,  whcrt.  tlicro  has  Ihti,  an  excessive  formation  of  granula- 
tion tissue.     Hoth  hone  and  eartilage  further  have  been  met  with  in 


Kki.  ti-J 


••■•Nv^;^.=^:5.1 


Me„„.la»i,.  fr„n.  a  cu.„.  „f  ...,„pi,.  „f  ,...,  l.l.,l,|,.r;  the  ordinary  gratified  .pithulium  bee 
replaced  hy  a  columnar  epitlieliiim.     (Afler  Knderlenj 


Via.  05 


"  ^ciis  nM'ta|)Ia.-.ia  in  il.n  wall  of  a  br.iMclui.s  (s„.ralled  "oHleoni-i"!-     n    .,„„„.„■  t.       v, 
.  ..;uo„^  ..nd.  ..  cartilage;  c,  eonnec.ve  ti.ue;  ,  ,  r^^l^^lL  :  r^Zli;  ^T::: 

^l'-  nrt.Tial  XV.!!  .^d  in  the  thi.luned  valves  of  c-lironi.-  en.ioeaniitis. 
''•'  '"'■t'"^'"  •'•XH'i'J'''^  l^e  necessary  it  exists  in  the  replacement  by 


206 


PROGRESSIVE  TISSUE  CHANGES 


1- 


bone  of  the  toiidons  of  orifjiii  or  insertion  of  the  muscle,  ns  in  the  so- 
called  "rider's  bone"  of  cavalrymen.  This  is  purely  local,  but  the 
same  process  is  probably  at  work  in  the  production  of  that  remark- 
able condition  mistakenly  called  myositis  ossificans,  in  which  the  tendons 
and  bodies  of  one  set  of  nnisclcs  after  another  become  replaced  by 
bone  until  finally  the  patient  is  unable  to  mo\e  his  limbs,  rotate  his 
head,  or  bend  his  back. 

As  has  been  referred  to  above,  the  devdoiiment  of  the  provisional 
callus  of  long  bones  after  fracture  is  an  example  of  cartila<,'inous  meta- 
plasia, and  the  same  is  seen  in  the  occasional  islands  of  cartila<:e  found 
in  new  growth  derived  from  the  connective  tissue,  esju'cially  in  the 
mixed  tumors  of  the  parotid  and  the  testis.  Wa  are  fully  aware  that 
this  is  generally  ascribed  to  the  presence  of  cell  rests,  but  there  seems 
no  reason  to  separate  it  from  other  cases  of  metaplasia. 

Hitherto  the  examples  given  have  dealt  with  the  metaplasia  of  less 
specializi  1  into  more  specializerl  liissues,  but  the  reverse  occurs,  as 
when  in  an  inflammation  of  the  joint  with  immobilization,  the  cartilages 
disapi)ear  from  the  joint  surfaces  and  are  replaced  by  fibrous  connec- 
tive tissue.  This  is  not  a  purely  tlegenerative  change,  because  inactivity 
of  the  joint  would  tend  to  atrophy,  but  results  from  a  change  of  function, 
the  immobility  of  the  joint  doing  away  with  the  necessity  for  cartilage. 

In  true  metaplasia,  finally,  we  have  no  new  process,  because  bone 
arises  first  in  the  fa'tus  from  mesoblastic  cells;  even  in  the  ])eriostenm 
of  the  adult  the  future  bone  corpuscles  may  be  indistinguishable  from 
fibroblasts  and  in  delayed  union  they  may  actually  be  con^•e^ted  into 
connective-tissue  cells.  In  foetal  life  it  is  their  environment  and  rela- 
tionship to  the  vessels  which  lead  certain  mesenchyme  cells  to  become 
osteoblasts  and  mo '•row  cells.  Why  may  not  the  same  reason  be  in 
existence  later?  A  'ifficulty  does  present  itself  in  the  idea  of  fully 
formed  cells  of  one  order  becoming  directly  converted  into  cells  of  a 
difl'erent  type,  but  this  does  not  happen;  metaj)lasia  is  not  direct,  but 
can  be  brought  about  only  by  a  preliminary  reversion  to  a  vegetati\e 
type  of  cell,  or,  where  mother  cells  are  present,  by  the  development  of 
cells  modified  by  environment.  When  we  speak  of  the  direct  conver- 
sion of  cartilage  into  bone  cells  we  mean  that  in  these  histologically 
simple  cells  there  is  at  least  a  functional  change;  that  this  is  not  merely 
a  supposition  is  shown  by  the  change  in  the  matrix  which  they  govern, 
and  by  its  exhibiting  a  regressive  modification. 


THE  NEOPLASMS 


Tiie  term  "tumor"  is  i)roperly  applied  to  any  unusual  swelling  in 
the  body,  and  includes  (1)  dislocated  parts;  (2)  collections  of  fluid  or 
gas;  (3)  tissue  growths,  either  physiological,  as  the  pregnant  uterus,  or 
hypertrophic,  and  others  "-iich;  ohvinu'^ly,  then,  it  can  b.-ive  no  useful 
specific  meaning  applicable  to  the  class  of  growth  we  wish  to  describe, 


v«r'^m-:^9m^i?fP!'jmiKa^B!mafi:!3^mm 


n^^xl^^^^SrvS^ 


THE  TERATOMAS 


207 


a  class  which  Thoina  called  the  "autonomous  tumors,"  that  is,  tumors 
winc-h  are,  or  possess  a  law  unto  themselves.  These  are  now  generally 
named  the  neoplasms,  or  new  growths,  and  the  process  b\-  which  they 
arise  is  known  as  neoplasia.  But  even  these  terms  are  not"  satisfactory, 
since  there  may  be  new  growth  set  up  hy  known  agents.  The  tubercle! 
for  example,  is  an  inflammatory  neoplasm  due  to  the  action  of  the  Ij' 
tuberculosis.  Despite  these  limitations  it  is  usual  to  emplox-  the  term 
'neoplasm"  to  indicate  the  autonomous  tumors  and  "infl'ammatorv 
neoplasm"  to  indicate  tumors  due  to  the  action  of  known  agents,  and 
in  the  following  pages  we  shall  fall  in  with  custom.  The  neoplasms 
proper,  therefore,  are  to  be  distinguished  from  inflammatory  neoplasms 
l)y  this  autonomy,  by  their  growth  indei)en(lent  of  function  and  of  the 
needs  of  the  organism  in  which  they  grow  and  from  which  thev  derive 
tiieir  nourishment,  and  by  the  fact  of  their  arising  independentiv  of 
any  known  stimulus.  In  the  matter  of  terminologv  we  emplov  the 
suffix  -oma  which  cannot  be  exactly  translated,  but  which  col.ven- 
tioi.,.ily  carries  with  it  the  idea  f)f  a  swelling,  and  more  specificallv, 
ot  a  swelling  of  the  above-described  neoplastic  nature,  although  excejv 
tK.ns  occur  m  the  case  of  such  words  as  hematoma.  With  more  i)ro- 
priety  than  m  the  last  named,  the  termination  bears  some  of  its  full 
meaning  in  terms  like  granuloma  and  tuberculoma,  for  these  are  "  tumors 
of  granulation  tissue"  and  "of  tuberculous  tissue"  respectively. 

To  gain  an  idea  of  what  neoplasms  are,  it  is  by  no  means  a  bad' method 
to  read  over  some  of  the  various  definitions  that  exist.  Cohnheim 
'l«s(Tibed  neoplasms  as  "circumscribed  atypical  productions  of  tissue 
'  -"n '  f  ■  •.<  ■  „  ^■'"'"■>'0"'^'  elements,"  stating  thus  that  thev  arise  essen- 
tially from  cell  rests,"  an  idea  largely  given  iipat  the  present  dav.  Ziegler 
-tiites  that  a  tumor  is  a  new  formation  of  tissue,  possessing  an  atypical 
stnutiire,  not  exercising  any  useful  function,  and  pre-r-ting  no  tvpical 
Innit  of  growth";  Lubarsch  counted  them  to  be  "gro^^  i  i  ^  of  apparentiv 
^dependent  origin,  histologically  correspoufling  with  the  cells  of  th'e 
matrix  from  which  they  arise,  but  atypical  in  form     .     .  "-von 

un.meisch  characterize<l  them  as  "local  degenerative  excess  of  growth." 
1  <Tl.ai)s  these  ideas  are  best  grouped  in  White's  definition,  that  :  neo- 
|.  asm  IS  an  (abnormal)  mass  of  c'lh,  tissues,  or  organs,  .  .  .  resem- 
I'Inui  those  mrmnlh,  present  hat  arramied  ati/pically.  It  grows  at  the 
'.rpnise  oj  the  organism  withont  subserving  any  useful  function." 


THE  TERATOMAS 

Tlicse  are  neoplasms  which  show  a  tendency  to  the  formation  not 

"il.y  o    irregnar  cell  masses  but  also  of  fully  formed  organs  such  as 

:^"n.  teeth,  skin,  hair,  bone,  or  secreting  glands;  for  example,  a  cvst- 

K.'  mass  cntaimng  many  of  these  tissues  may  be  foun<l  in  the  ovarv- 

t he  .n  anan  dermoid.    All  mr.n.tro.ities  are  terata.  and  such  have  bVei. 

•i>-  ussiMl  m  series  down  to  the  case  in  which,  of  two  individuals  from 


k'^ll^i 


208  PROGRESSIVE  TISSUE  CHASGES 

.1      4-    1 1  -  ,.f  t]>..  two  hecoiiifs  inf(>l»l»'<l  into  the 

individual,  from  a  separate  prunrt.ve  s  r,    U      U      «'>;,,     ,,„t 
the  parasite,     l  lie  tiraioma  i>  m"  _    i\.:.t„nl  ,,(  another  itidividnal 

.hat  kiiKls  of  eell  in  the  hcnly  m  ;^  ;'^  '  -'^^^^^;  ^  individual. 
Piviii,  rise  to  all  the  "-  ^-^^^  ,"^'  i^^^^u  ,„„  i,„e  ean  .lo  this, 
At  first  jilance  one  would  sa>  that  the  »    t'l/  ^  ,,„  ;,  i,,,,. 

hut  totipotentiahty  is  more  V^t^"";'\f,;3i'     „,    that  is.  one  that  ean 

they  remain  in  eonnee  ion  ^^.th  ^'h  ^  ^        ^^^^  "j       -^     ,,^.  forenumers 
taiuingno  yolk);  (4)  the  Kn-rmuial  h  as    ni  r        l  at  .  ^^^^^^^^^^^^ 

of  the  ova  an.l  spermatozoa,  and  U))  th«  '"«    '"      ^^     ,       '  ^,^     ,^,,„,. 
after  fertilization      ^^e  ^^^^  ^;^^:;^^;^^\Z.M: .  t^r.- 

^^"'"^  *"  ^^'^•'"^S'  .^m'ii     "u.  ;H^^  n;":f  whieli  have  already 
toma  can  arise;  the  torms  t h.it  tan  ar  j.   ^        ...nmiial 

been  ,lealt  with.  "-  '^  i;"^^  ^;,,  ^^^  '  "  ,^  monsters  one  of 
areas  on  one  germinal  xesicl  ,  gum,  nt  i  .    ,    ,  ^o)    The 

whieh  undergoes  inelus.on  ,n  ^.e  ;^ -^ ^  "rwhieh  become 
prod.etiou  of  ex-ess  or  inisi.laeed  ^''^M  <^^  "J'  ^^  ^^  ,  ^^  ,  ..^Iv  and 
inehule.!  in  the  growi^ig  "»>'^"1""V'  :' i"^  6  .«  i  .'/'.  or  may 
grow  elaborately,  giving  "-;^-;;;  '^  ;;^  ^     Sv        Mo.l^^d  inclu- 

d^^f^ihi^i-^d^^^^^^^^^^^^^^^ 


THE  TERATOMAS 


209 


liinl)s,  or  sexual  organs  project  from  the  mouth;  less  curious  are  those 
where  projects  a  mere  mass  of  flesh  in  whicli  can  he  distinguished  tissues 
of  the  various  kinds  that  are  ordinarily  derived  from  all  three  layers  of 
tlie  emhrvo—the  most  common  form  of  epignathus.  Sometimes  there 
is  merelv  a  tun)or  of  the  roof  of  the  mouth,  in  which  the  tissues  are 
simpler," and  do  not  represent  all  three  of  the  primitive  layers.  This 
last  may  have  arisen  not  from  totipotential  cells  separated  at  an  early 
>taf;e,  hut  from  nHiltii)()tential  cells  separated  at  a  later  period. 

Teratomas  of  the  Genital  Glands  and  Sporadic  Teratomas.— 'Phis 
class  comprises  s(mie  cases  that  are  clinically  very  curious.     Tlie 
cases  mentioned  ahove  of  cysts  containing  hair,  teeth,  etc..  hem);  found 
ill  the  .)\arv,  are  surpassed  hy  the  discovery  of  similar  tissues  in  the 
testis  of  the  male.    Of  such  neoplasms  we  find  thiit  some  grow  in  parts 
of  the  body  hearing  no  relationship  to  the  fissures  or  to  the  poles  of 
the  body,  or  to  the  generative  ghnds,  as,  for  example,  in  the  neck, 
tlic  anterior  mediastinum,  the  abdomen,  and  elsewhere.    No  rule  can 
l)c  laid  down  for  these,  and  we  are  able  to  say  only  that  there  must 
liave  been   a   development   of  displaced   totipotential   cells.      These 
teratomas     called  spomdircmhniomax—i-onsx^X  generally  of  tissues  from 
all  three  germinal  layers;  sometimes  the  tissues  are  of  adult  appearatice 
iind  of  limited  growth,  and  these  are  called  typical;  more  frequently, 
however,  thev  are  atypical,  appear  about  puberty,  grow  rapidly,  and 
tciiil  to  form  "secondaries.     This,  it  will  be  noted,  is  exactly  parallel  to 
the  occurrence  of  benign  and  malignant  l)lastomas  to  be  hereafter  men- 
tidiied.    Sometimes  a  tissue  in  a  typical  teratoma  of  this  sort  will  begin 
I,,  grow  inordinately,  the  result  being  a  neoplastic  growth  in  a  neo- 
plasm (tumor  in  tumore).    A  tumor  of  this  order  may  give  rise  to  distant 
metastases  in  the  body  of  the  host. 

Most  commonly  teratomas  are  found  in  the  ovary,  and  are  of  two 
Inrins:  (1)  the  large-cystic  teratoma,  commonly  called  the  "ovarian 
dermoid,"  and  (2)  the  "solid  or  small-cystic  teratoma.  The  former  is 
I  lie  commoner  and  may  attain  the  size  of  several  inches  in  diameter; 
its  contents  are  fatty  (Icbris  and  long  hairs  lying  in  a  varying  amount 
of  fluid.  It  is  lined  by  squamous  epithelium  with  sebaceous  and  sweat 
laiiils,  with  bone  frequentlv  to  be  found  in  the  walls  and  an  area  which 
ha>  been  called  the  "island,"  representing  the  head;  from  the  island 
arises  the  tuft  of  hairs  (in  our  experience,  always  red),  and  m  it  may 
!ir  I. one  in  which  are  fastened  teeth.  In  a  small  number  of  cases  the 
. Atremities  and  genitalia  have  been  recognized.  T\  pical  ovarian  tera- 
t.mias  of  this  kind  may  be  found  in  young  children.  The  solid  ovarian 
n  ratoma  is  like  the  sporadic  teratojias  already  spoken  of,  and  is  very 

■iHoinmon. 

With  regard  to  teratomas  of  the  testis,  it  remains  to  be  said  only 

'lat  the  so-called  mixed  tumors  of  the  testis  have  frequently  been 

imd  to  V  -long  to  this  class,  and  close  study  is  apt  to  reveal  tissues 

■       '  i:-rniinal  areas.    These  are  evi<i.>nt!y  the  product  of  totipoten- 


oio  I'KOf!riF^<IVE  TISSUE  CHANCES 

„,„».  ,.f  tlK-  p,nnmal  l'l«f '"'7  ;,  '"■  7,,,  V,  „  into  the  ovum  or 
„n«TSS  ..(  ,lev,Oopn«nt  .lo  ..o  i'l'  "  'V'''  ,|iff,re„t  mrts of  the 
Ik-  testis;  they  may  be  '""''■■' J  ;S'.:v",„e«.u.,t  tor  the 
S„I  o/S  ;^j;SZ:^^:^!!^  ■.  the  „at»a,  .te  or  these 
totipotontial  cells. 


TERATOBLASTOMAS 


T,K.s.  an-  n.<.plasn.  which  are  n.>t  ^^f;!^:Z:t^Z 
i,  them  .1..  net  rq^rpent  all  thm-  g^^rmm^^^^^^^^  ^^^  ^^^^  ^^ 

,nost  striking  exampes  ot  ^^^     ™'J^     \^ '^^^  one  mentions 

them.     A  very  fam.har  ^7"J^\  .  "^!,^^J^'^VSf  have  been  noted  so  fre- 
the  so^alled  "  sarcomas  of  the  lodne  ,  ^    ^         .         ,  ;„  „i^,a 

„ucntly,  growing  to  large  f  i;/"  ^^^  Jt^^^^    „\  the  IxhIv  one  must 

;Xti;e  £ai='^-  rr^S  -h  a  tumor  only  tissues 

I-Ki.  06 


,  .  '        ..  „t  ,h.-  ki,ln..x    »l.nwi,.«  Blan.1  tt.l.ulos  ,i.l.  st.rrnundinK  surt-n.u-Uke 
Socti.m  ..f  a  •■  ."ixptl  tun.nr     .if  th.  ki.lm  x  .    n         s  (Kibbert.) 

sueh  a.  „%ht  ,h.veh.„  ..an  the  "'f-' -;*,;li*^":?IU'^vh» 

we  n,™n  that  jnst  "»  *;;,';';^^;1T;S«^^^^^^^^^^  «<  *e  W'«>.  " 
eve  rise  to  various  structures  in  tit  iuik  .       ^ 

'impossible   to  find   in  a  renal   mixe.1   t""--;  ^    ^'^j,^^^ 

potentially  represente.1  in  the  myotonu.      ^ '^j,"",!,:   .i.-es  origin 

undergone  growth  in  its  normal  position. 

.  It  must  be  kept  in  nunti  that  the^  ^^^^^^J^S^X'^^-^ 
^S^t^,  i:^  1^1r^.i;^~-atode.  proper  ,>.  266). 


-MB^^P^P^IW 


4P 


TEliA  TOGENOVS  liLASTOMAS 


211 


It  is  ohvioiis  ill  such  u  tumor  as  this,  that  is,  one  arising  from  the 
iiiyotiiiiu',  that  all  the  eontained  tissues  are  necessarily  mesohlastic. 
'liitsf  neoplasms  are  large,  localized,  soft,  sareonia-like,  and  bleed  and 
ntcntse  reatlily;  on  section,  the  body  of  the  tumor  is  sarcoma-like,  but 
there  are  in  it  elements  that  recall  a  kidu'-y  tubule,  as  well  as  muscle. 
lihnius  an<l  elastic  tissue,  fat,  cartilage,  and  so  on.  Mixed  tumors 
of  ii  like  nature  in  which  the  tissues  vary  according  to  the  situation, 
jirc  found  in  the  parotid  gland  fairly  commonly,  less  so  in  the  sub- 
inaxillary  gland,  in  the  vagina  in  children,  in  the  cervix  uteri  later 
in  life,  in  tlie  mannnary  glands,  the  lacrimal  glands,  the  cheeks,  and 
the  gums. 

TERATOGENOUS  BLASTOMAS 

My  this  term  we  indicate  tumors  formed  of  one  order  of  cell,  but 
(iritritiatiiig  not  from  the  tissues  of  the  host  but  from  that  of  another 
iii(iividual  or  jjotential  individual  within  the  host.  The  simplest 
example  is  that  of  an  adenoma  or  carcinoma  developing  from  an 
(ixarian  teratoma;  the  most  interesting  and  important  are  those  devel- 
oping from  the  placenta,  viz.,  placental  moles  and  chorio-epithelioma. 
'lo  use  simple  language  at  the  cost  of  being  slightly  inaccurate  one  '"'•y 
(•\]ilain  that  the  hitter  is  an  interesting  form  of  tumor  arising  wi.,ie 
tlic  rajnd  cellular  growth  of  the  placenta  is  not  checked  at  the  birth  of 
tlic  fie'.us,  but  continues  growing  in  the  uterus,  producing  a  most 
malignant  and  fatal  neoplasm.  One  might  say  that  foetal  structures 
lial)ituated  to  rapid  growth  continue  in  the  uterus  after  their  physio- 
Inirical  purpose  is  fulfilled,  and  become  to  all  intents  and  purposes  a 
n(()|)lasin  of  the  blastoma  type. 

The  fd'tal  membranes  include  the  fa-tal  placenta,  which  is  an  organ 
1).  \'  loped  primarily  from  the  chorionic  villi;  being  epiblastic,  it  comes, 
with  tile  <levelo|)ment  of  the  allantois,  to  gain  a  vascular  mesohlastic 
((ire.     Hefore  the   placenta   develops,   the  outer  cell   layers  of   the 
t'dtal  chorion  have  "erode*!"  into  the  uterine  mucosa.    The  actively 
^Tdwing  cells  of  the  outer  layer  of  the  villi  are  phagocytic  and  penetrate 
iiiio  the  sinuses  of  the  uterus  below  the  mucous  membrane.    Normally, 
tin  ^e  cells,  when  they  have  penetrated  into  the  sinuses,  have  done  their 
wirk  and  the  outer  layer  becomes  ina<'tive,  fuses  and  forms  the  syncy- 
tium; below  this  at  the  time  of  birth  there  are  still  layers  of  active 
ei  lis    the  so-called  Langhans'  layer — but  these  also  undergo  degenera- 
ti  n  and  in  the  due  expulsion  of  the  placenta  at  parturition   they 
I  'Hie  cleanly  away  from  the  uterus.    But  in  cases  of  abortion  it  some- 
•  ines  happens  that  these  placental  changes,  usually  complete  by  the 
I  iiie  of  full  term,  have  not  yet  occurred  and  when  the  immature  fa'tus 
!    expelled,  there  remain  chorionic  cells  which  have  noi:  degenerated 
ill!  are  .still  iictively  growing.     These  constitute  the  evil  agent,  ami 
!i  y  carry  on  their  growth  in  the  uterus  and  constitute  a  neoplasm. 
Placental  Mole.     It  .sometimes  happens  soon  after  conception  that 
I"  fo'tns  dies  and  is  absorbed,  leaving  the  placenta  and  membranes 
-Lifted  upon  the  uterus,  and  these  form  an  irregular  tleshy  mass,  the 


;.;■:*•■ 


til 


^^s^ 


)!^£^ 


*jr~f.* 


^i^s^^^ 


TT 


I'*'. 


,.?i^ii^^ 


l-'i£hZ^^Jt^Wy^  'V»^ 


212 


VROCRESSIVE  TISSUE  CHANCES 


fleshy  mole,  proiu-  tc.  lieinorrliant'  (the  hemorrhagic  mole),  and  to  suhsc- 
qufiit  ptitrftiution  (the  putrefactive  mole).     Anaiii.  i..  similar  cast-s  the 


uhorioiiii-  villi  hi-iiiK  nourislitMl 


-mall  |>iini<m  i>f  ii  hvilatid  iiiolf 
nutiinil  size. 


l)v  the  maternal  blood  urow  actively 
aii<l  absorb  lluid  so  that  a  villus  be- 
comes a  vesicle  or  series  of  vesicles  of 
small  or  lar^e  size  distended   by   an 
(edematous  mucoid  fluid,  these  vesicles 
beiuK  a>;Krenated  tojtether  in  enormous 
numbers,  the  mass  distentlinR  the  uterus 
as  much  as  does  a  full-term  foetus  (hy- 
datid mole) .    The  \-esicles  are  \ello\vish 
and  translucent.    Even  in  an  otherwise 
n(.rmal  placenta  u  small  portion  of  it 
has  sometimes  been  found  to  consist 
of  such  a  mole. 

Chorio-epithelioma.  —  In  the  case 
last  mentioned  it  will  be  seen  that 
the  growth  remained  within  normal 
limits,  and  was,  therefore,  of  beiUK'n 
nature,  but  this  is  not  always  the 
case.  Such  a  mole  may  continue  to 
grow  and  fill  the  maternal  uterine 
sinuses  with  polypoid  masses,  the  so- 
called  "destructive  placental  polypi," 
which  show  a  kind  of  transition  to  the 
full-blown    chorio-epithelioma    maliR- 


Kiii.  fiS 


^>: 


rh„ri„..pi,h..li.,n.  .rlwin.  wlhln  ,ho  ru.     V,  .,.1,  „f  ..onno  »inu^N««.,  .nultinucle...  ,.  H^  of 

*^  -vnevtial  typ..;  /..  .-..  .■•■lis  ..f  I.iumhan.-.'  t>pc.     (Teacher.) 

num.  We  have  said  that  theouter  surface  of  the  Vl'f  ^^'•"^tH!Tde.■'!^y 
epiderm,  becomes  fused  to  form  syncytium,  wh.ch  ,s  made  of  du  ,.li 


!  c   i  "i 


THR  BLASTOMAS 


213 


>taiiiinK  cells  whose  hudies  huve  fused,  the  mass  renmining  multinuelear. 
IJclitw  the  syncytial  layer  the  cells  of  Langhans'  layer  remain  unfused, 
individual,  and  less  deejjly  staining.  The  syncytium  possesses  erosive 
plmgocytic  proi)erties,  and  it  is  these  masses  of  cells  that  tend  to  be 
-\\(l)t  away  in  the  hhuxl  of  the  maternal  sinuses  an<l  to  he  deposited 
ill  tlu'  capillaries  of  the  lungs  and  elsewhere.  Thus  we  have  these 
>.\  IK  ytial  cells  growing  actively-  either  in  the  uterine  sinuses  or  in  tissues 
tJM  where,  the  active  growth  of  the  syncytium  being  secon(le<l  by  the 
IK  tivityofthe  cells  of  Langhans' layer.  The  chorio-epithelioma  malignum 
i-  tlms  seen  to  be  a  neoplasm  entirely  cellular,  formed  of  large  actively 
M  L't  tiitive  cells  growing  entirely  within  the  vessels,  not  re(iuiring  an 
iiidiviilual  blood  supply  by  vessels  of  its  own,  not  capsuh.ted,  liable 
t(i  induce  hemorrhage  by  erosion  of 
the    vessel    walls    and    very    readily  Fm.  69 

ttiiiling  to  have  particles  carried  away  *  ' 

til  ^rrow  elsewhere.    With  such  char- 
ii< ttristics   it   is   no  wonder  that  we 
iiavc  licre  perhaps  the  most  terribly 
liitiil  (ifall  ncoi)lasms.     Although  the 
tnnnation  of  this  neoplasm  generally 
iiicnrs   shortly   after  an    interrupted 
|irri,'niiiKy,  yet  cases  have   been   re- 
ported occurring  years  after  abortion, 
11(1  intervening  j)regnancy  having  oc- 
ciirrci 
Tl 
:i 
the 


'I' 


rted  occurring  years  after  abortion,  ';#  S|f      AM 

i  intervening  i)regnancy  having  oc-  «ff^JP»           'ri 

rred.  f^'''  '  /■^'•^ 

The  difficulty  of  understanding  such  ^^>t*'^    JOi 

jinicess  of  growth   is  increased  by  ,*•'***  *'|^  fl 

elinding  of  this  growth  in  the  testis  '^      €>^^  ^.'.-H 

tlie  male.     Here  the  explanation  '«,/^*'         '*."  > 


Cells  of  a  chorio-^pithelioma  maliKDum, 
hiKliiT  nmKDificution.'  a,  syncytial  cell  mam; 
b,  ii'll.i  of  LanKhans'  type;  c,  brukon-down 
erythrocytes      (Von  Franque.) 


iMiiNt  he  that  cell  masses  of  this  type 

lia\e  developed,  not  as  the  outcome 

111  the    fertilized    ovum    and  uterine 

pri-iiiincy,    but    from    a    teratoma. 

The  teratoma  must  develop  or  tend 

to  ih  velop  a  chorion  and  so  gain  its  nourishment  through  this  chorion, 

nix.i.linj;  the  veins  of  the  testis;  the  chorionic  cells  so  developed  may 

lirnlitenite  in  the  testis  just  as  they  would  in  the  uterus. 

I'i  like  manner,  a  few  cases  have  been  rlescribed  within  recent  years 


III 

I'ol 


inch    Si 


.1 


li  sporadic  teratomas  in  various  regions  of  the  body  have  been 
examination  to  afford  chorio-epitheliomatous  areas. 


THE  BLASTOMAS   (ORDINARY   TUMORS) 

bhi-^+onias  include  all  tumors,  that  are  not  teratogenous,  which 
'  i!.  independent,  localized  growth.  This  gnnvtli  is  practically 
■  of  one  order;  yet  neoplasms  contain  a  stroma  (just  as  do  the 


m. 


E^J^^SP?i^s:^^^Si*iW^lJ^jT^IW^AW 


3  5^' ■.':». iiaii^-.  '\L 


^SEs 


214  PROGRESSIYE  TISSUE  CHANGES 

....n,al  tissues)  in  ^.i;h  ^t-n.a  r..  .  jU^n^^^^^^^ 

witl,  tlu-  exc-epti..n  ..f  tlu.sv    ["r;^,,^ ',''\J ;"",,!"' Wih    his  exception, 

tissue  like  that  win.  1.  '"""'*  *J"' ^^T'"-'..    .ml  r  ..f  tissue,  ami  are  in 

the  hlastoraas  are  ,r..wths  f''™;;;,;',:'\i.;;;;nt  tissue.;   ..r  example. 

nuinher  as  nu.ny  as  an.l  m„re  *  ""'^^''^/'^'^i^J ,,,,,, ^  ,„a  „ste..nms 

fihr.,n.as  of  fibrous  t.-»;y^'- ^  ^^s  gl^^^^n^^^^^^^^^ 

of  h.,ny  t!=^s»;-;  >«>•;•""-''  ^^^'^'^^J^  „fbln.tou,a  than  there 

of  (secretnijj)  ^lan.  s.     Ihin  are  """.'/'        J  •'         ,„^,n   or  Ki»«t- 

i,,^.  fn.ni  a  speeial  kuul  ..f  .ell,  '"»>  not  prisi  ,,f 

ordinal  crll  fully  .lifferentmte.1      J '^^     »  ^^f^  '\^^^ 
appnm.h  to  the  fully  f.-rnu-.l  an.l  fully  « '♦^^  "/^^^^^^^^^^^  fonn  .>f  the  .ulult 
tisiue.    Wh-n  the  "-'['•''-V^'^Cicrwht"   lu  nei^    m  this 

r*"""''T'r;Cu:c:!ii:a  "^^ 

hut  uni)erfe(tl\ ,  w hen  tl  i  ct  us  an         i  .  (.ounttr- 

„,oplasni  is  like  no  a.lult  "«>;'""\«'  f  ^^'^^ "^  *''%Sher^  as  a  general 
pari  eells  seen  .>nly  in  the  ^'">*;5";  '^'^^^^ f^^  , Jara.luU  tissuts,  the 
rule,  the  blast..nms  that  a  e  "^  t^^^\\f„^,,  ;V";'™  the  .ells  that  e.W 

als..  tlu-  maUgnant  neoplasms.  ,.„.,„.  ;„  eomnose.1  of  cells  and 

su.-h.  have  «r..vn  s  owly,  an.l  Ins  ^  "^  -  f  ^-h  is  essentially  a 
by  pr...lucinK  a  ssM  ar.mn.  ^^f'':'\''^^2sm\^onn'ih^u^^,^y^<^^^ 
p,rt  ..f  the  b...ly  tissvu-s,  an.l  "' ^/J^^^^^^^^^f^Tergowths,  an.l  .lo  not 
as  brain  or  b..ne,  are  n>«ip  * ".'' nerd  ru"e,  most  tissues  are  able 
rea.lily  pr...luce  a  capsule  I.  '^^''^^''J^^^^^^^  ,,„  often  be  shelle.1 
to  .•ir.un,scr,be  the  growth  so  that. uchne..pa^ 

m  which  It  lies,    lirowin,  in  ten.lencv  t.)  increase 

forme.1  of  inipertc.tl%  *""*^r'",*"    ',..•.,      rpiiev  snen.l  little  energy 
the  num-  to  expen.l  .m  mere  growth,  '^^^'.^    1^' f™,  '  5,;,  time  f..r 


1 


Tilt:  BLASTOMAS 


215 


si^ii  <»f  eiK-npsuliiMon;  «'vt'ii  if  a  capsiilc  ap|M>ar  to  the  tiaki'<!  rye,  it 
is  apt  to  !)«•  infiltrated  hy  thf  activoly  gruwiiij;  ncoplasiii;  tin-  rapid 
ffniwtli,  iiu-aiitinu',  hy  pressiirt'  i-aust's  atrophy  of  the  cells  of  the  orjjaii 
coiiciTiied,  s  these  die,  the  connective-  tissue  may  remain  as  a 

scatfoldinj;  on  which  the  neoplasm  hnilds  itself.  The  at-tive  growth, 
too,  tends  to  invade  capillaries  or  lymph  channels,  so  that  cells  or 
K'roups  of  cells  may  break  otF  from  the  neoplasm,  an<I  Ik-  carried  els«'- 
wlure  in  the  Innly,  where,  fiixliiiK  suitable  resting  places,  they  ^o  on 
with  their  growth  and  form  new  masses  or  tumors  Iikc  the  pan  nt 
growth.  Such  new  growths  are  denominated  metastases  or  secondary 
neoplasms. 

The  impression  gained  from  the  above  that  the  atypical  tumors 
are  malignant  is  almost  correct;  but  it  is  only  fair  to  add  that  the  above 
characters,  which  are  those  of  malignancy,  do  not  belong  tt>  all  atypical 
tumors,  for  there  are  malignant  tumors  (such  as  tlu-  malignant  mouse 
'  Micers)  that  do  not  readily  form  metastases  and,  «m  the  other  hand, 
there  are  tumors  of  benign  t.vpe  that  form  se«'(indaries;  we  have,  in 
fact,  all  grades  of  transition  between  tyj)ical  and  atypical  neoplasms. 
Yet  it  is  useful  to  gain  the  general  iriea  that  tumor-cell  diHerentiation 
for  specialixatioti  of  form)  has  a  definite  relation  to  benignancy,  aixl 
the  lack  of  it,  that  is,  a  tendency  to  the  vegetative  type  of  tissue,  has 
a  relation  to  malignancy.  It  is  upon  such  evidence  that  the  decision 
is  made  which  (U'termines  the  removal  or  otherwise  of  the  tunu)r  con- 
ciTued.  This  being  so,  it  is  very  essential  to  have  a  clear  knowledge 
of  what  is  the  adult  type  c  "  ell  from  which  a  particular  tumor  springs; 
for  example,  the  so-calletl  giant-celled  sarcoma  arising  from  the  bone 
marrow,  exhibits  cells  of  a  vegetative,  undifferentiated  type,  and  might 
on  that  account  be  called  very  malignant,  until  one  recalls  that  the 
jidiilt  Ixme-marrow  cells  are  of  this  type;  this  sarcoma,  as  a  matter 
of  fact,  is  one  of  the  least  malignant  of  all  sarcomas;  whereas,  a  mela- 
noma appears  to  be  made  up  of  more  diffjTentiate*!  spindle  cells,  an<l 
on  this  account  might  be  judged  of  mild  malignancv ,  yet  is  one  of  the 
most  malignant  of  tumors.  Emphasis  must,  then  .re,  be  laid  on  the 
necessity  for  knowledge  of  the  adult  tissue  from  whii-h  a  neoplasm  is 
supposed  to  arise. 

Malignancy.— It  must  be  understood  at  the  outset  that  it  is  not 
jiossible  to  lay  down  working  rules  by  which  a  student  may  surely 
know  whether  a  tumor  is  malignant  or  benign;  such  knowledge  can 
'•line  only  from  experience — from  the  "mental  pigeon-holing"  of  a 
number  of  cases  in  each  of  which  one  correlates  his  ideas  of  the  clinical 
history,  the  macroscopic  appearance,  and  the  microscopic  picture, 
and  his  theoretic  knowledge  of  location  of  tumors;  these  the  observer 
niciitally  puts  togetiier  as  one  ties  up  papers  in  an  elastic  band,  an<l 
liter  he  has  correlated  a  number,  he  begins  to  reach  a  state  in  which 
lis  intuition  tells  him  that  a  tumor  is  malignant  or  the  contrary.  Some 
I  the  rules  that  are  of  use  are  these: 


-^JM^7<rm: 


2ir> 


riioaREssivK  tissue  ciiasces 


correspoiurin^  (flls  of  tl.f  embryo. 

•J.  Rapidity  o!  growth.  ,       ^^,,  infiltrnfum  of  the 

H.  Periphor»l  exteniion.  with  huk  oi  «ap. 
siirroun<rnit!  tissufs.  .»...„„  , 

4.  Tendency  to  d'^'^^P  ."^•*"*"  ".;,,.*..,i    aiul  mv  the  expression  of  a 

All  of  tiHso  '-'v'"" 'T;;;;t  of  t  -m "...H..,' ti.sv,es. 

veijetntive  activity  Ik-voihI  that  ol  "^'/iiT  .  'I'his  can  l>e  readily 
''t  Tendency  to  Central  I>««*r:^;  ,,SJ  "arts  teiuls  to  e,>nstriet 

„,ulerstoo.l.  f..r  the  pressure  "''/""'"  f,,\i,^.  best  of  the  oxyt!*'" 
ill  vessels,  aiul  the  outermost  eells    >|^'  "  *  \.,i  „,•  ^Hese.  an.l  uls.. 

ll  foo.l  supply,  while  the  "'"-^/Xlnets"  degenerative  chan,.. 

.,f  H  free  outlet  to  their  ^^""^^'^l,^,^  so  that  the  central  part 

are  atn.phic  or  necrotic  or  at  »"',^    !",'.; „„face  tumor,  the  most 

'^'fli^bSr^ir recurrence  aUer  ^^^^1^^^^^^^^'^ 
that  the  removal  is  not  .;omp lete    ;'  ;  JX "nels  of  chains  of  cc4  s 

ii.g,  with  the  characteristic  yellow ish-gra> 

readily  recojinizaUe.  .  j  ^.^^^.\■,^^\.A,  for  which  indeed 

S.  Anemia.-  This  ««-«  hand  •}  '     "  ^^/^  jossof  red  corpuscles, 

anemia  is  partially  '^'fl"'"^'t.cnera  ion  show  that  the  blood  picture  is 
an.l  sometimes  the  ^>P"^  "^  J'^^^^'/^JVa^^  anemia.    Cachexia 

„ot  very  different  from  that  «^;^  ;^;^^^^^^^       ^^^  .j,,.  or  the  rate  of  growth 
however,  is  n..t  necessarily  mpnnH^^^^^^^^  ^^^  accoinpaim.!  by  very 

of  the  t...  or;  a  very  small  [/'^'^^.^^^  if  situated  in  the 

severe  cachexia,  and  ^^ain    hough  s«^>        V  ^,^^  ^      .j^^^  the 

crsophagus.  may  interfere  with  "J^*  ^^m"  ^^.^  .^ue  cachexia,  hut  rather 
cachexia  is  therebj  increased  ^'"^^^terrn  "cachexia"  to  describe 
starvation;  nor  is  '\^'*'"^'^.\f  ,fle  fo-l  pro<lucts  from  the  tumor 
those  cases  where  '^^^orptio  i  ^^  th  J'  ^\^^  ^^^  ^^^^  ^^^,^  ,^,  ^rue 
surface  have  occurred;  >et  Icumg  me 

cancerous  cachexia.  ,„*;r.n?    The  auestit)n  is  of  impor- 

Have  tumor  cells  an  internal  ^^<'^^^'^^  teen  "ong  consi.lered  as 
tam-e  because  cachexia  and  anemia  have  »^^^'  '"J^  Presumably 
Sts  of  a  specific  toxic  --^J^  ^^^^^  Xn  discharge  soluble 
these  in  their  growth  ^^i"  ^Iku-  f  g  j  ^|,,  „„ture  of  cn/.ymes, 
:^::^  ;^m!:^LSproSy  in  some  cases  cytolytic  as  well, 


TIIK  HLASTOyAS 


217 


so  that  we  nmy  iissnmi'  that  tlif  cacluxia  is  «lin><tly  tho  outc-ome  of 
|Mtisniioiis  |)r(Klii«-ts  of  cell  "u-tivity. 

Ill  th«'  nhnvv  parajtraphs  wc  liavf  Kivin  at  least  t-inlit  characters 
wliich  have  to  (h)  with  inaliKimiuy,  hut  we  would  once  more  add  the 
(imtion  that  all  of  these  may  u  •:  Im-  present,  that  the  reverse  of  s«»me 
of  them  may  Ik- found,  and  that  some  of  thes«'  very  characteristics  may 
1h-  seen  in  a  Imiuku  Rrowth,  so  that  we  have  yet  the  essence  of  inaliK- 
iianoy  to  discover.  Is  this  something  in  the  nature  of  the  cell  itself? 
We  think  so.  although  some  scientists  have  declared  «)n  the  contrary  that 
t  here  is  no  such  thiuK  as  a  nuilit?iuuit  cell  jht  hi';  hut  that  cells  have  maliK- 
iiaiuy  per  m-  is  proved  hy  the  fact  that  mouse  cancer  heinjt  passed 
throujjh  generations  of  mi<e  can  l»e  rendered  more  and  more  malvinant. 
Ml  that  there  is  a  constantly  increasinj?  numlwr  of  "takes,"  until 
(inally  1(H)  jht  cent,  of  animals  injectwl  develop  the  mouse  cancer 
which  has  been  convj-ywl  to  them.  The  malujnHncy  of  celh  it  deter- 
iiiiiied  hy  the  ijmile  of  veiietiiike  itourr  they  .show;  the  mnlinnancy  of  any 
ilicen  tumor  It  the  re.tuituiit  of  the  interactiun  between  cell  mal'ujnanry 
(iwl  the  resMmj  imwers  of  the  rent  of  the  organiitm. 

There  are  yet  other  forms  of  malijjnancy  (st>-called)  to  consider.  We 
liave  sometimes  heen  tempted  to  <lefine  a  malipnant  neoplasm  as  a  new 
srrowth  that  tends  to  kill;  if  this  he  true,  we  are  prepared  to  understand 
that  there  is  maliKnancy  in  virtue  of  site,  and  malignancy  in  virtue  of 
size.  Tor  example,  a  benign  tumor  that  in  the  liver  might  be  harinless, 
ill  tlu'  brain  might  cause  death,  or  a  large  ovarian  tumor  benign  in  its 
nature  may  so  press  upon  other  organs  as  ultimately  to  kill  the  patient. 
This  is  obviously  accidental  malignancy.  It  must  not  be  forgotten 
that  a  tumor  typical  and  benign  for  a  long  perimi  may  suddenly  assume 
ill  any  one  of  its  i)arts  rapid  growth,  a  .statement  which  can  be  under- 
>t(Ki<l  when  we  recall  that  nuilignancy  is  a  function  of  the  rate  and 
extent  of  the  cellular  reproduction  rather  than  of  cellular  proliferation 
it  elf. 

Metastases.  We  have  become  accustomed  to  consider  a.s  metastatic, 
ii.Hammations  in  which  the  agent,  bacteria  for  example,  is  carried  to 
;i  distant  part  of  the  body  where  the  tissues  react  to  its  presence,  so 
tliat  the  meta-static  inflammatory  overgrowth  is  made  up  of  the  body 
<  tils;  w ith  neoplasms  this  is  not  the  case,  for  the  metastatic  overgrowth 
is  made  by  the  multiplication  of  the  cells  of  the  original  tumor  in  the 
new  area.     The  mujTatinfi  rells  are  the  parmites. 

It  does  not  foiuiw  that  tlie  secondary  growth  need  faithfully  repro- 
•  hue  the  j)arent  growth.  As  a  matter  of  fact  it  generally  repnHluces 
tiie  t\pe,  but  is  often  more  actively  growing,  more  vegetative  and 
-iniplcr  in  structure. 

Modes  of  Origin. — Metastatic  growths  may  originate  in  four  ways: 

1.  The  cells  of  the  original  growth  penetrate  into  the  lymph  spaces 
iiiul  are  carried  in  the  lymph  stream  a  greater  or  less  distance  and 
lixlge  in  the  lymphatic  .system,  oftencst  in  the  notles.  Sometimes 
ill  llic  iicighborluHjtl  of  the  tumor  small  nodules  may  lie  found  con- 


m 


o,,s  PRnCRKSSIVK   TISSCK  Cll.WdES 

,,„,oun.p-  tlu-.n  t..  KHAV  as  a  l.Kal./e.l  n,as>  (1  ig.  .0). 


I'm.  70 


Vm    71 


,      ,         h  Croup  of  Do.lular  scrnmlary  growths 

C-ar.inoma  u.lvHn.md  aloriK  iIh-  ,„r.v.s.ular  lymptt  ^^  rouncl-...ll,.,l  .ar.onu.  P<'.'1«1  off  from 

,l,au..cls  of  the  hmt!  fro...  a  pl-u,  al  L'row.h  s,•oon.lar^  ^^^^    ^^^^^^^  ^  ^^^  ^^^^^  p.-rilontu...  in  a  ca-se 

,o  ,.ar,.ii.o.„a  of  the    l.r,a.st.     iDr    IU..-a  .     a    P-r.-  ^^^^^,  ••.,.,.,li„«"  of   the  pcr.- 

va.  ular  ..v...ph  ves..!  .l.s,....,l.,l  »i.  ,  ,a,.,cr  ,-.11      ^  «h        J     ^_^^_^  ^^^  ^^^__^ 
„lv,.ol„s  of  lun.;  c,  l.lo.»l  v..ss,.ls,  ,/.  «..o.,.lar>    1  u 
k,„,vti.-    ...filtra.io,.    of    the    p..riva»cular   eonueet.^.. 

"T  ,,,.  ti..n..r  in  its  ,n.ut1.  may  -'''IV,-;" -i^i^^l^^ir' sIS 
pass  tlimtly  into  tli.  f'^-''^ /''rea. ^^h^^^  ^^^ 

',,lls  ^vill  iH-  liable-  to  arn-st  •'>  ^lu"  ^  ■<    -  inlW>    nto  n      ^^    ^^^^  ,,f 


THE  liLASTOMAS 


219 


cavity  hvlun  rarriod  to  the  stoiiiach,  and  tumors  in  the  stomach  hciuK 
carried  to  the  intestines.  It  is  not  safe  to  junii)  to  the  cone  Insion  that 
a  secondary  in  the  small  intestine  has  found  its  way  there  by  trans- 
phmtation  even  though  the  primary  jjrowtii  he  in  tlie  stomiich,  for 
n  hert'  tiu-  extension  may  have  taken  i)Iace  hy  the  lymphatic  channel 


i'\t 


4.  Transplantatii 


■ceurs  hy  a/iponitioii.     Cases  are  recorded 


HI  which  fa)  one  |,  Iwing  invh  -!  in  cancer,  the  corresponding  point 
on  the  other  lip  h  s  he.  iiiiic  iiifc'  d;  (h)  the  skin  of  the  arm  in  contact 
with  an  ulceratin,    c;  rcinoniii  ol  the  breast  has  become  involved;  and 


in  which  (c)  the  \ 


le  pleural,  opjjosite  a  superficial  malig- 


nant  growth  have  become  tlie  site  of  transplantat 


ion  even 


wiien 


no 


esions  !)etween  the  two  have  existed.     The  jjrocess  of  nibbing  ha;- 


rom  the  first  have 


(Ih 
bared   the  second  surface,  on  to  which   the  cell's  f 
become  engrafted. 

Retrograde  Metastasis.— While  the  cells  are  generally  carried  by  the 
force  of  the  lymph  or  blood  stream  and  the  secondaries  are  tlnis  situated 
farther  down  the  stream,  nevertheless,  it  ma\ 
or  carrying  of  neoplastic  cells  is  in  the  directi 


occur 


that 


sucti 


growth 


.  .  HI  precisely  opposite  to 

that  which  might  be  expected.  Thus,  in  cancer  of  the  breast  one  mav 
find  the  head  of  the  humerus  of  the  same  side  infiltrated.  Yet  the  head 
of  the  humerus  sends  lym[)hatics  to  the  axillary  nodes  and  not  away 
from  them,  so  that  part  of  such  extension  nnist  have  liai)i)ened  against 
the  stream.  The  explanation  of  this  anomaly  i)robably  lies  in  the 
supposition  that  some  direct  channels  are  blocked  and  the  neoplastic 
cells  seek  out  collateral  routes.  We  have  to  remember  the  possibility 
that  the  extension  may  occur  by  direct  contiguity  of  growth  which 
we  can  imagine  jjreyails  against  the  lymph  stream' as  well  as  with  it; 
while  where  there  exists  a  negative  i)ressure  in  the  inferior  vena  cava,  the 
cells  may  actually  fall  back  from  tlie  inferior  vena  cava  into  the  hepatic 
veins. 

Unicentric  and  Multicentric  Primary  Growths.— It  is  ordinarily  not 
!)ossible  to  follow  a  tumor  to  its  earliest  beginnings,  but  we  have  good 
reason  for  supposing  that  most  blastomas  arise  from  one  cell  or  from 
a  group  of  cells  in  juxtaposition,  and  lu'oplasnis  which  thus  grow  from 
a  single  focus  are  unicentric.  Others,  liowe\er,  appear  to  be  pluricentric, 
that  is.  it  seems  that  of  a  number  of  cells  or  of  groups  of  cells  near 
one  another,  each  gives  origin  to  an  independent  mass  of  new  growth. 
'J'his  fact  tells  against  the  theory  of  cell  rests,  in  that  the  adult  cells 

an  organ  are  sometimes  seen  undergoing  change  into  the  neoplastic 
i.  pe. 

We  have  also  to  admit  that  it  is  possible  for  one  body  to  be  the 
seat  of  multiple  neoplasms  of  dift'erent  kinds  at  the  same  time.  It 
is  hardly  likely  that  these  deijcnd  one  upon  another;  more  likely  is 
it  that  a  lowered  bodily  resistance  permits  cells  of  various  kinds  and 
m  different  parts  of  the  b(Mly  to  undertake  active  proliferation.  It  is 
perhaps  due  to  the  same  cojiditiuii  that  we  sonutinies  find  bilateral 
organs  affected  by  new  growth  of  the  same  or  similar  kind.     It  is,  of 


wmi^s^w^m:^^. 


220  PROdRESSIVE  TISSUE  ClIANaES 

course,  possible  tl.at  one  of  these  •X;::^^^::^ '^o;th:;r 'i::^n 

wS'^^Stl  tl.at'in  sueh  a  case  ^^f^^l^^Z^^or.  some 
Tissue  of  Predilection.^  It  .s  notab  e  !  "^-Xrl  e  alL.st  sure  to 
tissues  are  very  likely  to  be  afleete.l,  ^^ ''  '^  \;  ;,  ^^^^^^ 
eseape;  an  example  is  seen  m  the  ^^^^^^^^^^ZtJ  in  the 
appear  in  the  liver,  an.l  the  seeonc  ar>  ^^^^J^^  grmvths.  The 
hones;  the  muscles  are  '•»"'>>V"'f't,,,.rent  parts  of  the 
meaning  of  this  is  tl.at  not  -M  -";;.«Xl.r^  h^^n  ll  ,f  the  bo.ly 
l,o,ly  are  able  to  prohterate,  tor  if/''  /^^  "J'  ^  J  ,f '.treugt^ 

of  the  bo,ly  fluids,  as  is  sh.mn  by  *''•;;;  ^"^f^i.^t-t.nsplantation 
tion  of  tumors  there  are  stajjes,  .luru.g  ^''  ",;';,/  ,"i„^,n(>  doubt, 
c-an  be  made,  while  during  others  sueh  an  «"^  "f^.  '  ^^^'^tanc-es  in 
to  the  existence  of  antafionist.e,  presumablx    extoht.c. 

''m"prii;^lL  of  Metastases  by  So-caUed  Bemgn  Tumors.  .Certain 
uZrof^Un  type  are  able  to  ^-^  -j;;-  ^Jlmi  ^.S" 
dromas.    Here  we  have  mult.pW     ^^^ ,  >  ^^^^^  //^^^^^^^^^^^  make 

not  dangerous.  It  is  not  possible  that       1    ^["^^j^^.^  ^^^  the  peri- 
their  way  into  the  pulmonary  ^''MJ'll'""^  ;       J  ^^^^^^^^^^ 
elumdrium  cells  (small  actively  growing  eel  s  t  ut     >•     :"j*^,^;'^  J„,,  \,,,;, 

of  a  chondroma)  which  are  -"f  \»":  ™"V  ke  ex  mjle  occurre.! 
pve  rise  to  their  normal  pn.du(|t-cal^^^^^^      A  1  K.  ^  ^^^^^^ 

'„u,  climcl  knowlclee  .-omp,!.  »  «"  "^P-  ,  '„i:S       '    ^l '  the 


THE  HLASTOMAS 


221 


satisfy;  however   important  it  be  from  a  clinical   standpoint,  it   is 
necessary  t  ■  find  some  other  basis  for  classification. 

Latency  ui  Metastases- It  is  seen  from  time  to  time  that  a  neo- 
plasm, successfully  removed,  may  break  out  in  metastases  years  after 
the  operation.  We  have  lately  seen  a  case  in  which  recurrence  appeared 
eight  years  after  removal  of  a  melanotic  sarcoma  of  the  choroid.  Have 
cells  from  the  origi'  "  neoplasm  lain  latent  all  this  time?  Presumably 
so,  for  the  same  pmnomenon  has  been  observed  in  transplantation 
experiments;  the  transjjlanted  cells  of  neoplasms  evidently  either  (1) 
grow  immediately  in  their  new  surroundiiifts,  or  (2)  lie  latent  for  a 
long  time,  with  or  without  eventual  multiplication,  or  (.J)  degenerate 
and  are  absorbed.  The  variance  of  these  happenings  indicates  that 
metastasis  depends  not  only  on  the  inherent  growing  qualities  of  the 
neoplastic  cells,  but  also  upon  the  resistance  of  the  tissues;  the  latter 
may  be  merely  another  way  of  saying,  as  was  said  above,  that  there 
is  a  preflilection  in  tissues. 

The  Nature  of  the  Stroma.-The  blastomas  gain  tlieir  nutrition 
from  the  host  and  possess  a  blood  and  lymph  supi)ly.  In  what  degree 
the  intervening  tissue  belongs  to  the  host  and  in  what  degree  to  the 
neoplasm  is  a  matter  for  consideration.  The  capsule  of  the  typical 
blastoma  is  formed  by  the  tissues  of  the  host;  even  in  a  typical  blastoma 
the  cells  at  first  make  their  way  between  the  supportive  cells  of  the 
host,  and  the  connective  tissue  of  the  host  thus  becomes  the  stroma 
of  the  neoplasm,  and  its  cells  grow  side  by  side  with  the  neoplastic 
cells.  Just  as  in  inflammation,  a  neoplasm  infiltrating  an  organ  may 
kill  off  the  specific  cells  of  the  organ  and  at  the  same  tim  imulat'e 
tlie  more  lowly  connective-tissue  cells  to  proliferation,  a.  '  this  at 
times  to  so  great  an  extent,  as  in  scirrhous  carcinomas,  that  die  con- 
nective-tissue overgrowth  acts  as  a  flirect  check  on  the  neoplastic 
growth.  In  an  atypical  connective-tissue  growth  (sarcoma)  a  double 
process  is  at  work;  the  stroma  itself  multiplies,  and  again,  as  the  sur- 
nmnding  tissue  is  infiltrated,  its  stroma  becomes  part  of  the  stroma 
of  the  growth. 

Blood  Vessels  and  Lymph  Vessels,— The  blood  \essels  and  lymph 
channels  of  the  host  are  retained  by  the  growing  tumor,  by  which  means 
the  tumor  is  nourished  and  gets  rid  of  its  excretions.  "As  the  tumor 
grows,  the  vessels  also  grow,  but  never  beyond  the  stage  of  capillaries; 
there  is  never  formation  of  muscular  walls,  or  of  arteries  or  veins  proper,' 
and  even  perfect  vessels  that  become  enclosed  in  a  growth  are  sim- 
plified and  lose  their  specialized  characters.  Thus  it  is  evident  that  a 
hlofitomn  hfi.t  uo  pow.-r  of  refiulatiti(/  its  blood  supply. 

Nerves.— The  host  supplies  no  nerves  to  the  blastoma.  A  few 
fibres  may  be  seen  to  pass  into  the  periphery  of  a  tumor,  but  they 
c\  idently  quickly  undergo  destruction  and  absorption,  and  the  deeper 
|)arts  of  the  tumor  are  without  nerves.  There  is  thus  no  trophic  or 
\  HMHuotor  control  exerted  on  the  tumor  by  the  body,  and  the  activities, 
vegetative  and  other,  of  the  neoplasm  can  be  influenced  only  through 


»n>; 


^'ji#33irni& 


-:5??^«*2^ 


222  riiocmssivt:  rissiE  chasoes 

t,„.  CO  nposition  of  the  l>o.ly  Hui.ls  an.l  ..y  alterations  in  the  resisting 

powiis  of  tlu'snrn.nn.hnu  tissues.  j,,  ,^ 

Degenerative  Charges.  ^^^^^  ^  l^'J^^  extent  control 

neoplasm,  espeeiall.N  sn.ee  the  ».•"»*"•!'  ^*       ,      j  .  tumor  .-ells  have 

its  'own  m.trition;  apart  »-;"  'i;:;; '^  ^^  ^^^^ 

no  other  s.,uree..tmn.nshnu..tl  ant      Hn.^>^<^^^^^^^  ^,^^  ,^^.^^  ^,,,, 

ami  of  this  the  peripheral  V^^'^V    ,.    t   Iv  lit  off  tor  f.Mnl  ami  ..xvpn. 
most,  leaving  the  centrally  situate  1  p.   t  •;»'>;"   ,j  ,,j  t,,^;.  ,,ts 

N„t  only  this,  but  the  peripheral  cells      a>   f,e  .  ^^^^^ 

hv  .liffusi..n  into  the  snrroun.hn^'  'Tt  ^V  n    Le     or  kille.i  tnerehv. 
niust  "stew  in  their  own  juice^  ^^^^;Zo!ln  internal  neo- 

b:  J:r;^^  ^:/:r  .i;^i.r.!t5!^::Ue  liahle^    .upture 
and  permit  hemorrhajie. 

Fic.  "a 

2 


Irrciiuliir    iiutoscri   in 


,:uacr    cells:    1,   hypo.hromatic    mi 


tosis;    2,    asyinrnclric   niUosia,  the    upper 


(liiunliler  nurli'us  liyperr 


hronmlic;  3  I"  7.  various  forma  of  multipolar  mitoses. 


(Galcotti.) 


given  tumor    >et   m.  n^    "^^  .^        ^-^^^.^  hvpochromatie  (that  is. 


H''ffiBfi^«KrJKir"*'^,^<S 


CLA8SIFICATI0S  OF  THE  AUTOCHTHONOUS  liLASTOMAS     223 

Retrogression  and  Healing.-It  is  by  the  help  .,f  ti.ese  .IcKe.ierative 
HmnRes  that  retrogressi,,,.  and  even  .hsappcannut-  and  ahscrpti..,.  ,.f 
tum.,rs  ..mir,  although  this  result  is  an  unusual  one.  Manv  cases  of 
.lisappearanee  of  tumors,  even  the  m,.st  malignant,  have  been"  reported 
and  It  ,s  upon  this  possibility  that  we  can  base  hope  of  attaining 
ultimately  a  means  of  cure;  even  now  we  know  certain  means  that 
l.aye  met  with  a  measure  of  success,  such  as  the  use  of  arsenic  and 
salts  of  selenium  and  tellurium;  of  Coley's  inoculation  ttuul  of  sterilized 
eultures  of  streptococcus  and  B.  prodigiosus  (based  on  the  experience 
that  intercurrent  erysipelas  may  lead  to  the  absorption  of  malignant 
jrrowths);  of  extirpation  of  the  ovaries  in  mammarv  carcin.nia-  of 
electropuncture  in  uterine  myomas;  and  of  ultraviolet  and  the  Iloiitgen 
rays  upon  superhcial  growths.  *' 

CLASSinCATION  OF  THE  AUTOCHTHONOUS  BLASTOMAS 

It  may  be  here  repeated  that  the  autochthonous  blastomas  are 
neoplasms  which  arise  in  a  body  by  proliferation  of  cells  belonging  to 
that  body ;  this  ,s  to  distinguish  them  from  heterochthonous  (teratogenous) 
blastomas  which  arise  in  a  body  from  cells  belonging  to  another  individ- 
ual. Ihcre  IS  perhaps  no  word  in  the  language  which  convevs  precisely 
tins  meaning  an'l  we  are  compelled  to  use  this  clumsv  term!  In  devis- 
uig  a  classification  it  is  necessary  to  remember  that  finalitv  of  knowledge 
of  tumors  IS  far  from  being  attained,  and  it  would  be  unwise  to  attempt 
to  claim  finality  for  any  classification  made  at  the  present  day  the 
intention  is  to  construct  a  working  classification  along  the  lines  of 
t  .e  origin  of  the  various  tissues  affected,  that  is,  an  embrvogenetic 
.  iassification,  and  this  beeause  our  microscopic  diagnosis  is  dependent 
upon  cell  characters. 

This  is  not  the   place   to  deal   particularly   with  already  existent 

iliissincations. 

Kach  tissue  in  the  body  has  a  definite  origin  and  mode  of  develon- 

in<nt,  and  if  neoplasms  are  derived  from  definite  tissues,  and  their  com- 

l-.ient  cells  represent  stages  in  the  development  or  the  retrogression 

"    these  tissues,  it  becomes  necessary  to  distinguish  an<l  possible  to 

Hassify  tumors  according  to  the    tissue  from   which    the   neoplasm 

>|rn.gs.     Considering  the  earliest  stage  that  has  been  recognized '  in 

H.  development  of  the  fertilized  ovum  after  it  has  begun  to  segment 

I  :.t  IS,  the  morula,  we  have  merely  a  cluster  of  undifferentiated  cells' 

l-pidly  these  cells  arrange  themselves  into  two  layers,  the  epiblast 

■■r'\  hypoblast.    Hetween  these  the  hypoblast  and,  to  a  less  extent,  the 

•1 1  .last  giv    rise  to  a  jxx.rly  diflVn-ntiated  mass  of  cells  hardly  to  be 

-j  lc<l  a  lay,;,  the  mesoblast.     The  reader  must  correct  the  old  idea 

Mt  connective  tissues  and  connective  -'.sues  only  arise  from  meso- 

;  ist;  and  that  epithelium  and  glaiuL  _d  nerves,  and  these  alone, 

t.  Ml  epiblast  and  hypoblast.    From  the  epiblast,  for  example,  ther^ 


^9^!^;%^  'f^i'sn^a^'^mst?'^ 


224 


PROGRESSIVE  TISSUE  CHANGES 


is  (levelopod  aloiif;  tlu"  dorsal  groove  u  muss  of  crlls  of  which  tliose 
awav  from  the  surface  ar»>  no  longer  stratified.  As  the  dorsaU'roove 
becomes  infolded  this  portion  becomes  cut  off  from  the  rest,  the  only 
part  recalliiiK'  the  original  epiblust  being  the  epcndymal  layer  arouiul 
the  central  canal,  these  cells  having  originally  been  outer  layers  of 


Fig.  73 


OiuKrammatir  ropresontiition  "f  portion  through  vcrt.-bratc  body  to  show  r.ntogenct..-  rchition- 
,hip  of  tho  varin,i8  orders  of  tissues.  .1.  Of  lepUli<-  type:  1,  epi.lcrn.  ami  its  glands  (epi  .last";! :  - 
murous  momhrane  of  digestive  canal  and  its  glands,  liver,  etc.  (hypol.lastic) ;  3.  endothehum  l.nmg 
serous  cavities  (mesoblastic)  an.l  glands,  like  renal  cortex,  of  moso,  helial  origin;  4,  vascular  endothehun, 
of  late  n.esoblastic  origin.  B.  Of  hylic  type:  5,  spinal  cord,  b.ain.  an.l  nerves  (ep.blastic) ;  6,  n.>l..- 
rhord  (hvpoblastic) ;  7,  connective  tissues  of  the  body  (mescnchymatous) ;  H,  myotomes,  atnatcd  musck 
of  body  Unesothelial).    C.  Cavities;    9,  lumen  of  digestive  tube;  10,  body  cavity. 

the  dorsal  groove.  A  similar  ingrowth  of  cells  occurs  from  the  hypo- 
blast to  form  the  notochord.  We  find  that  these  ingrowths  from  the 
epiblast  and  the  hypoblast  come  into  most  intimate  relationship  sub- 
sequentlv  with  mesoblastic  structures.  The  mesoblast  in  its  turn 
undergoes  changes;  when  it  splits  to  give  origin  to  what  will  ultimately 
be  the  primitive  body  cavity,  or  ccelom,  the  cells  lining  that  cavity 


ms^trr 


'    VS..''S.«'.*-«»,»r-i*  'Sis.'' 


CLASSIFICATION  Of    THE  AUTOCHTHONOUS  BLASTOMAS     225 


'.icomp  arranged  in  a  layer,  the  mesothelium:  tin;  rcmaiiiitiR  part  of  the 
nifsohlast,  which  dot-s  not  become  so  ditlVrcntiated,  constituting  the 
mesenchyme.    From  the  mesothelium  again,  there  occur  ingrowths  into 
the  mesenchyme  wliich  are  comparable  to  the  ingrowths  from  the 
epiblast  ami   hypoblast;   these  are  the  myotomes,  the  anlagcn  of  the 
luture  striated  muscles  of  the  body.    Further,  a  mass  of  mesenchyme 
wiiicli  will  ultimately  l)e  recognizable  as  the  heart  ami  trunk  vessels  are 
seen  to  develop  a  central  cavity,  and  the  mesenchvme  cells  Iving  upon 
this  cavity  become  differentiated  into  a  definite  layer,  the  endotheUum. 
Ue  thus  find  that  th"  embryo  becomes  divisible  into  collections  of 
two  orders,  which  may  be  termed  "lining  membranes"  and  (for  lack 
ot   a  more  expressive    word)   "pulps,"  the   lining  membranes  being 
persistent  epiblastic,  hypoblastic,  mesothelial,  and  endothelial  layers, 
the  pulp  being  the  main  mass  of  the  neuroblast  (of  epiblastic  origin), 
the  notochord  (of  hypoblastic),  and  the  mesench\nie  (of  mesoblastic) 
15riefly  expressed,  each  layer  in  the  original  embrvo  becomes  differ- 
entiated into  lining  membranes  and  pulps.    To  the  former  we  apply 
Lr',.*''™   "^•Pi!"c."   (from  /.sr/c,  a   rind   or  skin),  and  to  the  latter 
hylic    (from  'J/.r^,  crude  material),  both  words  being  used  as  adjectives. 
1  he  characteristic  of  the  lepidic  tissues  is  that  the  cells  are  arranged 
111  layers  or  clusters  in  direct  apposition;  they  are  not  separated  by  h/niph 
or  hhnd  tesseh,  an.l  they  possess  a  supporting  framework  or  stronia  of 
liylic  tissue  in  which  run  the  nutrient  vessels.    The  features  of  livlic 
tissues  are  the  opposite;  separating  the  celh  there  is  a  matrix  of  inter- 
rrlhilar  substance,  either  homogeneous  or  fibrillatcd,  while  lymph  spaces 
"11,    rrsseh  and  blood  capillaries  tend  to  separate  and  run  between  the 
nidimlual  relk.     If  in  the  lepidic  tissues  there  is  a  stroma  of  hylic 
tissues,  so  in  the  hylic  tissues  there  is  lepidic  tissue  in  the  shape  of  the 
emlothehum  of  the  bloo<l  and  lymph  vessels,  in  each  case  the  elements 
ot  the  other  order  being  subordinate. 
On  this  basis  we  obtain  the  following  classification  of  normal  tissues: 
1.  Lininj;  Membrane  or  Lepidic  Tissues,  in  which  the  blood  vessels  do 
iiHt  penetrate  the  groups  of  specific  cells  and  in  which  there  is  an  ab.sence 
"   .lehnite  stroma  between  the  individual  cells,  although  such  stroma 
"I  iiiesenchymatous  origin,  may  be  present  between  the  groups  of  cells- 
I .  Epiblastic:  Epidermis.    Epidermal  appendages,  hair,  nails,  enamel 
"teeth,  etc.   Epidermal  glands.  EpitheUum  of  the  mouth  and  salivary 
^rliiiKls.    Epithelium  and  glands  of  nasal  tract  and  associated  spaces 
!•;<  ermal   (anterior)  portion  of  hypophysis   cerebri.     Lens  of  eye 
I  I'ltliehum  of  membranous  labyrinth  of  ear,  anus,  male  urethra  (except 
iTMstatic  portion).  ^ 

.-'    llypoblastic:    Epithelium  of  digestive  tract  and  glands  connected 
I'll  it.     bpecihc  cells  of  liver,  pancreas,  tonsils,  thymus,  thyroid. 
1  I'ltlielium  of  trachea,  lungs,  bladder,  temale  urethra,  male  urethra 
l|! "Static  portion). 

^  '.Mesothelial:     Lining  cells  of  pleurse,  pericanlium,  peritoneum. 
•     'ihc  cells  of  adrenals,  kidneys,  testes,  ovaries  (Graafian  follicles) 
15  ' 


226 


i'i«)(!iii:ssi\  !■:  rissiH  cH.WdEs 


uttTiis,  vajriiia,  vasa  (Mvt- 


Kpitlielium  and  nli»"l^  •'*'  ••■"11"1>'""  *"'"■ 

or  niav  not  he  hlood  and  lytni)li  vossi-ls: 
1     'l-'i,lhl(i.''tlr:    Nerve  cells,  nenronha. 

T    !Kw>^  '—-•.•    tissues,    cartilage,    hone, 

reii  Jmn  ::f  hnM.h  .lands,  hone  n.arrow.  fat  eells.  n.v..luntary  muscle 
tissue   spleen,  hK.od  vessels,  hlood  corpuscles. 

4    i/,lo//,Wm/;    Striated  nu.scle.  in.ludu..  canl.ac  nms,  e 
Kollowing  this  sehen.e  of  classiHcafon  ot  the  -"-  J  ;^'  ^^^  .X 
now  divi.le  the  tnn.ors  arisinj;  from  tne  ;^l'^'''f'y,:"  '^'•^";.''    ';!„.;i*Jl^ 
various  tissues  into  t.„  n.ain  ,c-nera-  the  l^'^'-    "■-•;-  ^^^jf,^^ 
oripnatiuK  fn>.n  the  ahove  "luuug-n.emhrane     ^'^r^-,*^;  '     \.  ^^^^^^^^^^ 
tumors  ..r  hylomas.  originatinK  fn.m  t,ss  u s  .lenve.l  '>•''"!  ";>;^^^^ 

'•  ,uh.  '•    Wo  can  further  .listin.nish  tvvo  hroad  groups  <>t  lep.du  tmnors 
puip.  ».»>'  derived  in  d  rect  descent  irom  the 

tlw  nniiiarv    those  ^^  io>e  (en>  <irt   miuvki  m 

«  - M^i'^l-t  and  hypohlast;  and  seco.ulary.  or  trans.t.ma^   .W 

cells  -.rc  derived  in  indirect  descent  fn.m  the  same   i.  > .,  ha%t  passed, 

.Uu   course  o    devc-lopnu-nt,  through  a  n.esohlast.c  or  mesenchyma- 

uZ^^  lu-f..re  conung  t<.  forn,  portions  of  a  '-^n-;^--^  ,,^^^ 

The  coinage  of  new  tern.s  in  a  suhj.'Ct  .s  "•"'*'^'  ''  '^;'\'  '^^^ '   "  r";',",. 

or  new  relationships  are  to  he  expresse.  .  unavo.dahle.  ^1''-  ->  *  '  /^'^-^ 

e  circun.stan  es  un.ler  which  lepi.lic  an.l  lep.doma  and  h.xhc  ad 

1     V    were  su>^gested.    Thev  are  necessar>  for  the  expression  ot  tins 

;:  ;;i:;of  ;^mor  relatiou;hip.  hut  at  present,  we  ;^-;i,;'>-  - 

•,  fruiework  on  which  the  idea  of  tumor  growth  is  t(   he  l.uilt,  rath  r 

;     ;         erms   or  everv.hn  employment;  in  fact,  we  .io  not  personally 

'nCin  hlr  daily  dinicai  purposes,  for  which  t--  hke  car.^^^^^^ 

sarcoma    and  en.h.thelioma  are  adecinate.      ihese  terms  (••'"»»•"  J; 

w  ';: nile  that  u.m:.rs  of  id.nti.-al  type  may  ..rigmate  trom  any  .^ 
he  u  rn  la^ors■  thus,  a  lepi'li^"  .aninoma  can  arise  from  ep.hlastie. 
;  ..^:h;:iic:'  :;  mcsohlastic'stmctures,  and,  what  is  --  -"^^^ 

in   ts  malignancv  according  to  its  origin;  we  think  it  nece>s.  r.  ,  th  r 
r     t       PI  Iv  an  a.lje.-tive  which  will  indi.'ate  its  tissue  relatmnship, 
:  ;      iXllal  ;arci,u.ina.  mes.>the!ial  carcinoma,  or  n>.tlu-ln.  a,  ei.oma 

liulotlulial  adenoma,  and  so  on.    We  are  aware  'V''^";  'h    ^V  Z 

nients  which  can  he  urge.l  against  this  method  ..t  nomenclatun ,  hi 
"n   .,:  allowe.1  to  sta^-  its  chief  advantage,  v-  the  recogm^ 
t,„:  secialary  or  traditional  f-''P^-     '^,-:/j;;;  !^  ^  rcw!^-. 
lepidic   tum..rs    wiuch    are   liai.le    to    prisitit   tn"'^"'  „  tnmor 

.„  ,1  t..  cause  therehv  the  greatest  contusion.     I'or  exampU,  a  tumor 
ottlK  adrenal,  a  "hypernephroma"  of  the  kidney,  an  " ovarian  tumor, 


ini.OMAS  AM)  LKPIIiOMAS 


<>: 


27 


iiiiiy.  if  of  slow  ^n.wth,  prcsi-iit  all  tin-  cliaracttTs  of  a  carcinoma— a 
;;lim.liilar  tuiiK.r  and  if  rapi.lly  KrowinK  and  activciv  vegetative 
may  he  mori)liolo^'ically  a  perfect  sarcoma.  Such  a  tumor  was  often 
culled  carcinoma  sarcomatodes,  and  in  some  instances  has  actually 
Im(ii  proved  to  possess  certain  characters,  su|)posed  to  he  distinctive, 
ct  each;  for  instance,  sarcoma  cells  are  separated  hy  fibrils  of  stroma,' 
( iircin«|ma  cells  are  not,  yet  a  comparison  of  V\iis.  71  and  7.")  will  shew' 
thiit  FiK.  7:>  shows  a  tumor  that  is  in  this  regard  at  once  a  carcinoma 
iiiid  a  sarcoma. 


Fui.  7' 


Km.  7.1 


'I'll  "f  rarriniiiiia  sir^  \  i>f  lirnaist, 
I  «itli  Mallory'M  cunn*  iiM-tissuc  stain, 
"■"risirair  a  (•(iiniilcK' abxhri'  of  passage 
'  I'lllular  filiril.«  hrtwrrn  llic  itiiliviiliial 
"  i~"f  llicaivci.laricll  Knmps.    ( Wi,i,ll(.y.) 


.S'ctinn  iif  an  ciKlnthclioma  similarly 
tn'ali'il.  The  hIv..i,Iii»  Im>I.,w  rcarts  almost 
wholly  liki-  an  rpithdjal  ,ari<iT.  that  bImivo 
(■xhihit>  intiTci'iliilar  ronni'i-tivc-tissuf  fibrils, 
liki'  a  sarcima.     (Woollcy.) 


Tl 


/■'■ 
hit 
tin 


ri  : 


;■  reason  endotheUomas  (for  example)  are  trmmtmuiJ  .seems  to 
I'N.  We  have  insisted  before  ui)on  the  fact  tiiat  the  rarlii'.tf.  arqiiirrd 
■  rlivx  „j  c'lh,  or  of  individuals,  arr  flic  laxt  to  he  Imt;  properties  of 
'■  ac(|iiiri'ment  are  yielded  up  with  greater  ease.  The  i)rimarv  lepidic 
>r^  are  derived  directly  from  cells  that  from  the  earliest  eml)rv()nic 
"I.  have  been  lepidic  and  of  the  nature  of  lining  membranes-  "while 

Imimtnwal  <,r  secondary  lepidic  tumors  are  derived  from  cells 

-'■   from   bemj;   lepidic   (in   epiblast   or  hypoblast)   have   become 
vjlien  the  mesoblast  was  formed)  and  yet  later  have  ajiain  taken 

■1'  ic  characters.    These  colls,  „r  their  prt,scn\  in  neoplasms,  revert 

'    t"  the  hyhc,  sarcomatous  type,  which  the  primary  lepidic  tumor 

111  ii>'t,  l)ecause  these  last  have  been  continuously  lepidic.    This 


228 


rnncREssivE  tissue  chasoes 


h  not  to  state  that  primary  U-pi.lic  tiiinurs  ijomt  rryrr  .  for  tlu>>   .K 
„ot..ri..usly   in   tin-  case  of  tho  .o-<alI.-.l    •M.asal-r.iiM    c.ar...M.m,  s 
which  Rreatlv  rosi-inhh-  sanoinas;  hut  th.-  contention  is  that  ^hc  nnr- 

tumors,  whih-  it  is  an  exception  in  tlie  case  of  the  prnnar> . 

It  niav  he  h.i.l  .iown  as  a  ruh-  in  all  tn.n..rs  that  tlu-  nu.re  rapul  the 
^n.vvth.  the  ,n..r.-  .lo  cells  lose  those  featnres  that  were  fornierly  specific 

to  them  as  the  constituent  cells  ot  this 

K„.  Tii  or  the  other  tissue;  the  in«li\  iiliial  cell 

^v  inav  thus  atl'ord  little  or  no  chie  to 

^/V' :••-.:•  •;  the  tissue  of  oripn,  hut  hy  the  Ken- 

^^ii;.*:-lj-  "•'         eral  arrangement  of  cells  it  is  pos- 

^^'^<^tl^''.'.        sihlc    to    see   at    least    reseinhlances 

■*"      ^*--  •         to  connective  tissues  or  to  glandular 

tissues,  and   thereby  to  know  wliat 

kind   of    tissue    pive   orij,'iii    to    the 

tumor.     We    note,    in    any    case,    a 

reversion  to  a  simpler,  earlier,  more 

•'embryonic"  type  of  tissue,  in  which 

l)roliferative   or    vegetative    activity 

has  replaced  functional  activity  and 

caused  the  tissue  to  lose  those  features 

that  are  distinctively  connected  with 

the  performance  of  functicm.    With 

this   loss   of   power   to   perform   its 

function,  we  ht-iieve  the  tissue  to  he 

incapable   of  repiininf;  the  same;  a 

hvlic  tumor,  beinn  comi:)sed  of  tissues 

of  less  specialize*!  type,  cannot  take 
on  lepidic  characters.  An  apparent  assumption  of  such  ;:';»>-';;;tf';;;.;; 
seen  in  Fij;.  77,  but  even  here,  although  the  cells  which  line  the  c> s 
cavitv  that  has  .U-veloped  in  a  ghoma,  have  the  appearance,  at  first 
glanJe,  of  epithelium,  they  are  not  so;  there  is  no  '>''-";V"\;";-^,'- 
and  the  case  is  merely  one  ..f  a.lai.tation  ..t  jjlioma  cells  to  tulhl  the 
function  of  lining  cells. 


■•l'siiiil..-<'|)illi('li\lin."  or  fu'cimrlaryopillii- 
lititji  nilhiiut  biiwiiiinl  nii'inliniiio  liniiiK  ii 
cyal  in  h  glimiiH,  fi.nncil  by  in(.ilili<-!iti.m  nt 
the  HillKTfirial  hiyor  of  islionja  rc-lh.     (Suxcr  ) 


TYPICAL  HYUC  TUMORS  OF  MESENCHYMATOUS  ORIGIN 

Bef..re  dealing  with  the  large  (piestion  of  causation,  we  shall  pass 
in  review  the  various  forms  of  tumors.     Here  it  is  necessary  to  .lra^^ 
a  distinction  between   blastomas   proper   an.l    blastomatoid    grovrths. 
The  blastomas  are  well-<lefined    an.l    aut.-Momous  '"<l^-ir"*^^;''*  ";;' 
growths;  the  blastomatoi.l  growths  are  conditions  '»ti'rn'r«l'«tr  h^J^ 
simple  hypertrophy  an.l  these  true  tumors.    In  connection  ;^'  ^  tu    ; 
formati..ns  from  a  great  variety  of  t^sues,  wt  -""'""t^'V^tTe       us 
mediate  growths,  and  while  we  realize  that  m  time  some  of  these  forms 


Bi^!TIS!Sr 


":irsiF*^r'--#'iffl». 


♦«-ir"i.  « 


FIBROMA 


229 


"t  overKruvvtl.  rn.,y  I,,-  U-Uvt  inMl.-rst<MHl  an.l  may  c.in,.  t«.  I.e  indu.!.'** 
^mmi.i;  M.iipl,-  liy,„.rtr..|.hi,.s.  y.-t  at  tlw  prrsn.t  we  liavr  to  >;r..ui>  tlim 
.!>  havinj:  n.aiiy  n-s.-inMaiHrs  t..  tiiiiior  f<.nMatioi,.  Tlu-s.-  ov.rirrovvtlis 
'"  l.last...„at..i.l  naturr  (of  whi.h  lipoiimtusis.  film..nato.sis,  nnin- 
il.ro.natosis,  kIu.s.s.  vW.,  ar.-  .•x,.n.plc.,s).  as  «  class  (1 )  am^t  one  par- 
ti.nlar  t.s.s,u.;  (2,  ar,.  niultipK.;  are  of  .-oupMHtal.  if  not  here.litarv. 
nriirin.  froqnn.tlx  I„.„,k  n.ai.ift-st  in  ,-arly  life  an.l  affectinK  several 
ni.n.  KTs  of  a  lannly;  ,  J)  may  InMliHuse,  or  if  not  .liHuso,  at  least  mertje 
into  the  snrroun.hn^^  tissue;  (f,)  may  appear  to  he  e.uapsulat.Hl,  hut 
this  apparent  eneapsnu.tion  is  merely  the  limit  imposed  hv  the  houmlarv 
ot  the  tissut- afleete.|;  ((i)  are  (.f  slow  growth.  exten.lii.K  "ver,  it  maV 
:"•.  years;  (/)  eventually  may  take  on  malignant  characters,  which 
1^  n..t  a  characteristic  hut  is  merely  an  example  of  the  priiKij.le  that 
n>M,e  winch  has  develoj.ecl  m  excess  of  function  is  alrca.lv  nu.re  than 
M  t-vvay  t..war.l  a  , errancy,  that  is.  tlu>  stinuihis.  whatever  it  is.  that 
1"!  t..  hlastomatowl  gr.wth  may  lead  to  true  hlastomatous  growth. 

Fibroma. -The  fibr.>ma  is  a  typical  tum..r  of  fibrous  connective 

""■•  I  ^Ti"  .;/"  *'"'*  *'•''  '■"''-''  ^*'"'  *""""•)  '^  "  ^'•"«'  i'nitati.)n  of  the 
or,:;mal  the  hl.r..us  connective  tissue);  the  origina!  tissue  lies  wi.lelv 
M.it.nd  thr..ughout  the  body,  so  that  sn.-h  a  tunmr  niav  arise  iii 
jM.iny  situations.  Just  as  .•onnective  tissue  varies  in  its  exposition, 
I"  m^'  m  some  regions  l.mse  an.l  are.,lar,  with  rclativ.-lv  frt^uent  cells 

""'.', ^f'"^'  ''^•';«" "»"'  ««•"'.  ^vith  relativ.-ly  few  cells,  'which  are  neces- 

^;mlv  .•oinpressed,  s..  the  tunu.rs  vary,  an.l  we  liave  soft  and  hard 
il.ruHKis  from  these  tissues  respectively;  the  soft  aris...  for  example 
ro,„  snb.utane..us  tissue,  the  har.l  fr..m  dense  tissues  such  as  tendons' 
t.i-i;r.  an.l  i.eriosteum.     All  alike,  however,  are  composcl  of  con- 
n- t.v.-tissue  cells,  connective-tissue  fibrils,  s..me  elastic  tissue,  and 
-.vessels.     Lymph  spaces  are  seen  in  greater  .,r  less  prominence 
.  'ord  ng  to  whether  it  ,.e  a  soft  or  a  hard  fibr...na.     The  fibr.,ma 
.n.  rally  forms  a  well-,lehned  no.lule  which  gr..ws  slowh-.  an.l  ,,resses 
P'.n  and  replaces  the  tissues  near  it;  if  tluTc  be  rapi.l  growth,  however, 
'1^'   'His  instea.l  ..t  resembling  fully  .levelope.1  comie.-tive-tissue  cells 
;|n   N  e  hbr.>blasts.    The  greater  the-  ten.lency  to  r..s..mble  fibnlli^t:; 
"I  li...  I,.ss  .liHerentiation  there  is  in  the  .lirecti.m  .,f  perfecti.m  of 
.||.me,.tive-tissue  ...lis,  the  nK>re  .l..cs  such  a  growth 'approach  in 
>trM  ire  a  sarc.ma;  the  .M.ly  sure  differentiation  between  the  benign 
;"    >  I..;  malignant  (sarcmatous)  growth  is  the  absence  or  presence  of 
;t.   ..n,  an.1  mvasion  .,f  surrounding  tissues.     Lest  .,ne  should  be 
-  •  .1  It  IS  well  to  remember  that  all  fibromas  are  n...re  cellular  than  is 
r     ,1  adnlt  c.)nnect.ve  tissue   and  the  growth  .,f  a  fibroma  of  the 
;  locent  kind  occurs  by  the  proliferation  of  such  fibroblasts,  and 
""'      inlly  formed  connective  tissue. 
I    .   Hbrum.-,  is  pale  on  section,  and  the  firmer  ones  are  glistening, 
n  appearancr  that  recalls  watered  silk;  this  is  .lue  to  the  bancls 
-  that  run  in  all  varying  directions,  each  band  bting  originally 


■ ■'^'SW^JSBi>iiS^^jm 


*-rrV'       r:-i*4 


kJZ 


'^n' 


W 


..jI 


230  i'H(K;iiKssi\  F.  Tissrh:  ciiASdES 

|„i,l  ,|o«n  imn.11.1  tn  .,r  iumn.l  a  I.Io.mI  x.smI  A  Mcti....  tl,ronK».  tV..> 
tui.H.r  will  sIm.vv  M.Mir  Imn.is  .ut  transv..r>.l> ,  ..tli.rs  l..„«m..lmall.v. 
„,„1  otl..T->  nl,li(,n.lv.  Ill  tlM-  Kn.>s.  tl.r  »il.r...,.ii  is  uvuvrMy  sharply 
nmiinMril«.l.  aial  .an  mi.iilv  I.,-  .nu.l.atr.l,  i.ut  tlu'  >l.arp  l.nmaiarv 
liiH-  camu.t  I..-  s..  w.ll  Mrii  mul.-r  the  ini.roscop.'.  lw(aii>f  tlu;  siir- 
roun.iii.^'  tisMif  is  of  tin-  saiiu-  .ml.r,  aixi  tlu-  iiormal  aii.l  tum..r  tissn.-s 
pass  rnulilv  into  om-  aimth.r.  i  i       „    . 

I),'H.-n.Tativi-  ihnuiii's  arr  i)n.m-  to  occur  in  hl.roinas.  an.l  l.v  arrest 
of  hloo.1  supi.lv .  or  l.v  tci»ioii  they  im.lcr»io  necrosis,  an.l  m  tin-  n.-.T..so.l 
area  is  inn.l.  chol.-st.rin  an.l  fatty  material,  whi.h  snhse.pi.iitly  may 
|„.,.,„ne  .-..nverf.!  int..  .•al.-ar.'..ns  n.Mluh's.  If  th.'  lymph  ..uti.ts  Ik- 
ol.strn.ted,   the   tnn...r    may    hec.me    .clematous.  lymi.hannie.tati.', 

evsti.',  or  niu...i.l.  ,      ,        ^i  i 

'  In  certain  situati..ns.  as  in  th.-  mammary  nl"'"'.  "  hl.roma  ma\  h« 
fo.m.l  to  have  in  its  mi.lst  jrlan.lular  el.-m.-nts;  this  pn.hahly  m.-ans 

that  an  inflammat..r^  fihn.sis  has  taken  ..n  tnm..r  h.rmati an.!  t  a- 

|o.ali/e.l  fibroma  thus  f..rn..-.l  has  iu.lu.l.-.l  ulan.ls  that  were  ..riKmally 
n..rnuil;  su.-l.  a  tum..r  is  a  pnr.-  fil.n.nui.  an.l  n..t  a  fil.r..-a.len..ma;  it 
is  a  fil.ro-a.l.-n..ma  ..nly  when  there  i>  a  i.n.liferation  ol  tlu-  n.cin.l.-.l 
dan.lular  .-l.-nu-nts.  Asa  mutter. .f  fa.-t,  there  is  a  p....l  .h-al  ..t  loosen.-.s 
in  ..ur  us.-  of  th.-  tern.  Hhr.>-a.len..ma;  s..me  ..f  th.-s,-  are  pur.-  h  .n.nu.s 
with  iilan.l  tissu.-  in.-lu.le.l.  an.l  ..thers  are  not  a.tual ly  tru.  hl.n.nias 
at  all  hecanse  the  fihn.us  tissue  is  n..t  (-ircmns.rihe.l  (haston.a), 
hut  is  general,  an.l  .litTuse.  ..f  the  nature  ..f  a  l.lastomat..i.l  ^r'-wtlj. 
True  fihn.mas  .io  i...t  form  nu-tastas.-s  an.l  .1..  not  r.-cur  att.-r  removal; 
if  rcurrence  .l...s  happen,  it  m.-ans  .-ither  that  the  s;r..wth  was  ..nuinally 
sarc..mat.>us  or  was  fil.r,>mat..i.l.  in  whi.h  latt.-r  .ase  th.-  n-cnrren.e 
is  simply  the  exi.r.-ssi<.n.  ..nee  m..re,  ..f  the  .lilVuse  overjrrowth  whu-h 
was  orijiinally  wholly  t.r  partly  remt.ve.l. 

Hard  Fibromas.  Hani  fil.n.mas  are  f..nn.l  in  many  .iifl.-rent  situa- 
tions hut  m..st  ..ften  in  .•..nnc<ti..n  with  t.i..l..ns  ..r  fas.ia-;  this  rule 
is  n..t  al.s..lut.-,  f..r  we  find  them  in  soft  tissu.-s  sii.h  as  the  ki.ln.->.  A 
vari.-tv  ...-ciirriiif;  in  .•onne.tion  with  th.-  jaw  is  epuUs,  a  term  oft.-n 
impn.'perlv  ^iven  t..  ost.-..i.l  and  osti-..sar<  oinat..us  j;r..W  s  in  this 
situation;"  it  .leveloi.s  from  th.-  i.eri..st.um  in  .-..iiii.;<ti<.n  with  lie 
r....t  ..f  a  .lecayed  to<.tli.  I'terin.-  fil.n.mas  and  "til.roi.ls  will  l.e  .li.- 
(-usse.l  with  the  myoiiia.s  ..f  that  or^'an. 

Soft  Fibromas.     Thes.-  are  frecpi.-ntly  multiple,  an.l  many  ..f  them 
are  fi».r..mat..i.l.    Th.-y  are  m..M   fre.punt  in  the  skin,  pharynx,  miu 
.ligestive  tract,  a'  '  th.)se  in  the  nose  an.l  throat  are  apt  to  he  soil 
mass<.s-  muc.i.l  p  '.ps-.if  the  tru.-  myx..Hl.romat..us  type. 

Fibromatoid  Growths.-  M..st  i-omm..nly  these  o<<ur  in  the  submu<..us 
c.,nn.-.-tive  tissue  of  the  p..steri..r  nares  and  pharynx;  an.l  t..  he  inchu  .^^ 
am..nn  them  also  are  s.,me  cases  ,.f  "neurofibromatosis."  t''t'  ^•-''"1^ 
"von  Recklinghausen's  disease."  whic!>  is  a  h!a  .tnn.it....l  ovcr|r_ruuth 
of  the  medullate.1  peripheral  nerves;  it  is  asserte.l  that  the  "i>tH  •  « 
„lfact..rv  nerves,  whi.'h  are  .levoi.l  of  sh.-aths  of  Schwann  an.l  .)t  tlie 


Hlili<tM.\~riit:iJ)!n 


231 


<.lls  that  ar..  |>r.-ciirsnr>  ..f  tl.,-  sheaths,  an-  ....y.-r  iiivolv..]  i„  .-hs^.h 
"t  iniiltii.lr  n.Mir..hl.r..ma.  vH  thr  upti,.  imtv.-  is  thr  m  at  of  tnu-  Hl.ro- 
n'at..s,s.     i„  xUvsv  casrs.  th.Tf  is  .s.mir  rch.f i..i,>hi|,  l„.txv,.,n  fh.-  til rs 


I' I.I.  :r 


Kici    78 


■■'Hi 


'    "^^^-Ik-   •     ■Hi      "-'  .;   <^i     ' 


'Ks^y. 


t 


M;int  fihrorin,       (ItiM  , 


*   'It  tihroriKi 


iii'l    •■t ruction  of  the  lymph  channds.  \vi 


lr.,iii   tl 


If  system  of  tht-  tis 


lurvcs  arc  distinct 


I  Ills  to  lie  (hic  to  s( 
th 


isiics  they  traverse;  tl,.    (iistiirhed  niitrit 


hundred    or  more 
n  jinrted  cases  of  fihroma- 


imc  vice  of  ih'\elo|)ment  hecaust 


ion 
many,  if  not  all. 


tn.iN 


.f    th 


urred 


e    optic    nerve 


7!) 


in    carl\ 


lif 


('   or 


"•re  familial. 
Cheloid.i     Althou>;h  dis- 

iiiMt  ill  its  I'tiolo^'y,  aim 
I  what  in  its  liisto!o>;y, 
I'id  is  closely  related  to 


-Hill 


illiatn^ 


It 


consists  III 


Aces-i  vedeveloi)ment  of 


•iitaiieous   fihroi 


IS    COll- 


i'"n\c    tissue,    sometimes 
i-Tcat    as    to    produce 
'-'•>>\('rlappiiij;  masses  of 


l;i 


Liniwti 


d   ski 


1      covered      hv      coar™.  hyul 


Section  fri)tn  a  ttrnwlh  in    a    rn«-  of   clitloiil 


n.    Two  fi 


line  ronitfrtivf>-r)KNiic  V 


)nn<llf 


to  show    the 
■■*.     (Aft.T  Kibbort.) 


are 


I-   \v 


I)reseiit  in  its  occurrence:  (1)  a  congenital  predisposition,  and 
atioii  or  injury.  It  is  especially  common  in  ncf^rocs,  and  in 
i<>  sufier  from  it.  a  slijrht  cutaneous  injurv  is  liable  to  he  fol- 


I'V  its  (level 


opmciit.     In  a  case  studied  in 


our  own  laboratory, 


•iiii'  aiitliorili-'s  write  this  k-i'l<>i<|    from  »'>-.    ■)  jT-ih'-  -l-.w  "-        '1 
.>  m  «iii..|,  „„.  ,,r,„.,..ss..s  spn-acl  i„t„  tho  st.mMm.iinK  <'<Ti..m);„t'h;.|^'r'Moi^l" 


PROGRESSIVE  TISSUE  CHANGES 


232 

•  i  1  „„ +1,..  fnrearm  with  a  force  sufficient 
the  mere  running  of  a  pin  point  a  ong  the  forearm  ^  aevelopment 
to  cause  reddening  but  not  W*^-  "S'  ^^^^  of  the  pin  Although  some 
of  little  fibroid  nodules  «l«";^,^^,f '^  V'  Xable  that  in  all  cases  it 

s.:^  •£.  i::  ^^^  -—  «^  ^  -'^^  ^^"^ "" ''' 

^'^Sicr-scopically.  there  is  "o^^^;;;^^  ^Lr^Sl^S^^e 
imperceptibly  into  the  '«   "^^^l^^eo^s  bundles  or  strands  of 

'iSiSlble  to  spontaneous  absorption,  and  steady  pressure  may 

be  followed  by  disappearance.  whether  we  ought  to  regard 

Myxoina.-Some  P'-^^hologists  doubt  ^^he^^ht^^^^^^^       K^  ^^  ^^.^^^^. 

the  myxoma  as  a  tumor,  aiul  consider  ^hat ^^^^  sh^^^^^^l^.^^  ^^  ^^^^^  ^^^ 

Fio.  HO 


SO,-. ion  from  ty,.i.al  P"r.i..n  of  a  mu,-.,i.l  ...lyp- 
((^.llection  of  Hoyal  Victoria  Hosiul"!) 


of  the  various  forms  ot  con- 
nective-tissue   neoplasm  —  of 
lipoma,  chondroma,  or  fibroma 
—using  the  term  lipoma  myxo- 
matodes   rather    than    myxo- 
liiuia,  etc.   This  is,  to  a  great 
.xtent,  true  but  pure  myxomas 
of  the  endocardium  have  been 
describeil,  and  myxomas   are 
sometimes      recognizable     at 
birth.     The     mucoid      nasa 
polvps,   so   frequently    called 
myxomas,  follow    chronic  in- 
flammation of  the  nose,  and 
are  often  not  mucin-contain- 
„   ««  the  oedema  i?  sufficient  to 
ing,  b.it  mereU   -'-^Xmltirti    ue  H  "iraining  is  prev^ted, 
weigh  down  the  mass  of  »""a'""™^^'  ;>  \ .     ^^^^^^^  cumulative,     borne 
,uul  the  con.lition  beconu-s  progress!  ^i^^^^^  -^^^^j,^; 

few,  even  nasal  polyps  ^-';^^;;^l''^TvJ.n.h\^  is  not  to  be  found 
The  tissue  ^^1»«^^\  ^he  n.vxoma  most  r  ^         j  j.^^,,.,,  as 

in  the  adult  body,  but  is  the  tissue  "    ^Tt^^^^^^^     fattv  tissue  of  the 
Wharton's  jelly,  an.l  t  -'^^'vehW     '^^^^^^^^^^  ;^,,„,,  i„flani- 

f„.tus.    In  pathological  states.  ^^  7>;  ^j,;^,  ^trix;  we  realize,  in 
matory  areas,  fibroblasts    y.ng  ma -^^^^^^^^^  ^^^  ^^^^  ^y^ 

fact,  that  mucin    which  IS  a     '°^,«IJ,';„„,Vissue,  and  we  recognize  a 
connection  with  the  development  of  fibrou    t^s  ^       ^^.^^^  ^ 

connection  with  this  ^«^'*^'"P™f"*  ^^  „^Xd  mvxoedema. 
but  in  the  generalized  «^"^'"7^J*  ™^^  '^te  cells,  or  polyhedra 
V  true  myxoma  >«/"'"P«^'';   '^  .!t°„£  cell" ' ) ,  which  are  separated 
ftt::  =ri?^::;:^Snt:£  U^,  t..  mucm  ta^mg  a 


LIPOMA 


233 


In  the  matrix  run  large,  thin-walled 


ilifferential  stain  with  thionin. 
vessels. 

The  tumor  is  slowly  growing,  soft,  and  fluctuating,  so  as  to  seem  at 
times  cystic.  It  forms  no  metastases;  a  certain  number  of  myxomas 
do  become  sarcomatous,  and  when  they  do  the  metastases  are  purely 
sarcomatous,  and  show  no  myxomatous  characters. 

Lipoma. — The  lipomas  are  sharply  defined  tumors  composed  of 
tatty  tissue;  even  if  situated  in  the  midst  of  fat  there  is  no  difficulty 
in  recognizing  the  tumor,  even  if  its  color  be  not  paler  than  the  sur- 
ruuiiding  fat,  as  it  often  is;  there  exists  some  difference  between  normal 
fat  and  the  fat  of  a  lipouia,  for  where  a  large  lipoma  is  present  the  botly 
may  progressively  emaciate  and  yet  the  fat  of  the  lipoma  will  not  be 
taken  to  supply  the  botlily  needs.  The  lipomas  are  usually  single  but 
may  be  multiple,  and  vary  in  size  from  the  very  minute  ones  observed 
ill  the  kidney  to  the  G3-pound  retroperitoneal  mass  which  has  been 
described.  Generally  rounded,  they  may  have  finger-like  processes 
radiating  into  surrounding  tissues.  They  grow  slowly  and  do  not  recur 
after  extirpation.  Modifications  may  occur,  such  as  that  part  of  the 
tumor  \vhich  becomes  jelly-like  and  mucinous,  the  lipoma  viyxomatodes; 
ail  unchanged  lipoma  may  even  be  so  fluctuant  as  to  be  taken  for  a 
localized  collection  of  fluid;  at  times  a  kind  of  necrosis  is  followed  by 
the  development  of  oil-containing  cysts;  cartilage  and  even  bone  have 
been  found  in  lipomas,  a  phenomenon  which  is  probably  to  be  accounted 
for  l)y  metaplasia. 

Most  frequently  the  lipoma  is  subcutaneous,  especially  in  the  region 
of  the  shoulder  and  arm;  a  curious  clinical  fact  is  that  one  of  these 
tumors  under  the  influence  of  gravity  may  change  its  position  and 
lie,  for  example,  lower  down  upon  the  arm  than  was  at  first  the  case, 
internally,  they  occur  in  the  submucosa  of  the  intestine,  in  the  kidney, 
ill  the  brain,  in  the  omentum,  and  as  enlarged  appendices  epiploicse; 
liponiatous  processes  may  develop  in  connection  with  the  joints,  pro- 
jecting into  the  synovial  cavity,  as  in  the  knee. 

Lipomatoid  Growth. — More  or  less  generalized,  often  regional,  lipo- 
matosis occurs.  Steatopygy,  an  excessive  development  of  the  fatty 
tissue  of  the  buttocks  is  counted  a  point  of  beauty  among  the  Hotten- 
tots, and  is  so  frequent  that  it  must  be  counted  racial.  Lipomatosis 
atl'eetiiig  certain  areas  may  be  familial;  and  the  good  results  sometimes 
<>l)taine(l  from  the  use  of  thyroid  extract  suggest  that  the  occurrence 
1^  due  to  a  nutritional  disorder;  and  in  fact,  a  diseased  pituitary  has 
I'teii  found  in  at  least  two  cases  of  adiposis  dolorosa,  a  disease  in  which 
tlie  presence  of  the  excess  fatty  tissue  is  associated  with  severe  pain. 

Xanthoma.— The  xanthoma  is  a  small,  benign,  fatty  tumor  of  a 
yellow  color,  subcutaneous,  sometimes  multiple  (X.  multiplex),  often 
toiiiul  near  the  inner  canthus  of  the  eye  (X.  palpebrarum).  Formed 
"f  connective  tissue,  it  contains  yellow'  fatty  globules,  in  which  the 
piKiiient  is  of  the  nature  of  a  lipochrome.  Jt  is  probable  that  the 
xaiitlionia  is  not  a  tumor  but  a  fatty  or  lipochrome  degeneration  of 


^%m13 


234 


I'ROaUESSIVE  TISSUE  CIIAXGES 


II 


m 

[■ii 

{'i'i 
ill 


m 

Li 


ri.i.  s2 


tissue.    The  iniiltiplt-  form  is  found  associatfd  with  diahi-ti's  (X.  dia- 
beticorum). 

Chondroma.  (Iioiulroinas  arc  tuuiors  of  cartilafii-,  liyaliiu"  (hyalo- 
enchondroma),  fihrous  (flbro-enchondroma),  or  ri-ticulatcd  (reticulated 
enchondroma).  Tlu-y  may  lu-  sin^h-  or  multipi*-,  and  in  fit'iioral  have 
a  (hstiiiet  fihrous  capsule.  There  are  two  varieties,  tlie  ccchondroma, 
and  the  cncliondroma.  of  whicli  the  former  is  an  outj;rowth  t)f  cartilage 
where  such  is  normally  i)resent,  as  in  the  costal  cartilages,  the  larynx, 
the  trachea,  and  t-lsewhere;  they  are  truly  local  hypertrophies,  and 
are  to  he  considered  as  chondro- 
nnitoid.  In  the  chondroma  proj)er, 
or  enchondroma,  we  have  to  tleal 
with  a  mass  of  cartilage  having  no 
connection  with  a  parent  matrix. 
Such  occur  in  many  regions,  notably 
in  coiuiection  with  the  !)ones,  the 
parotid,  the  submaxillary  glands, 
the  testes,  the  mammary  glands, 
the  lungs,  and  more  rarely  in  the 
ovaries,  the  corpora  cavernosa,  and 
otlier  organs.  They  do  not  arise 
from  the  cartilages  of  joints,  although 
they  may  deciop  in  the  fringes  of 
the  synovial  meml)ranes,  forming 
the  "  loose  cartilages"  of  joints. 

Fl<i.   hi 


Knchniulroiii:!  cxIiilHline   rali'iirniiis  iiifillr:iticiii 
<K     li'In/iruin).      (UiMicrl.) 


Ecchondroinji  of  finitcr.     (Shophonl.' 


As  in  normal  cartilage,  few  or  no  blood  vessels  are  found  in  tlie 
substance  oi  the  tmnor,  and  for  this  reason,  if  large,  the  mas>  is 
lobulated,  the  intervening  connective  tissue  carrying  the  blood  vcsmIs. 
In  the  large  growths,  the  deei)er  |)arts  give  place  to  bone  (osteo-enchon- 
droma).  or  calcareous  infiltration  occurs  (enchondroma  petrificura). 
There  is  also  considerable  tendency  to  central  necrosis,  and  if  a  necrotic 
area  o|)ens  to  the  exterior  it  is  apt  to  be  very  intractable,  and  leii 


(^llOXDRO.\fA~OSTEOMA 


235 


eniK..  an.l  slowly  Kr.,vvi„K  as  thvsv  tumors  arr.  novortl.oless  th.-v 
;-■.    m„„  ,„  1„.,H.H,  a„,l  thm-  ,l,..v  „ri  „re,.„  .'.m  ,„to  '  w   h  V^ * 

usreoma.-jJsti  )mas,  defined  as  tumors  havinc  a  crowtli  ,,f  tL\^ 
Mr.„.,.ss  "*'  ""'"'  "^  *''''   '•"""'••"lis  examples  of  this 

,^ip9.;;;xf  Kr^';;x^s;™  sls^''i:z 


236 


PROGRESSIVE  TISSUE  CHANGES 


often  shows  no  cartilaginous  fore  stage.  Ossifying  chondroma  serves 
as  a  further  example  of  the  heteroplastic  form. 

Osteomatoid.— This,  as  was  stateil  above,  includes  all  cases  of  localized 
or  general  overgrowth  of  hones  in  which  the  growth  is  not  defined 
from  the  normal  hone,  is  not  independent,  and  is  t>f  unknown  cause 
(save,  perhaps,  that  heredity  plays  a  part). 

Such  are: 

1.  Idiopathic  hyperplasias  affecting  one  or  several  bones,  especially 

the  long  bones. 

2.  Enustoses,  localized  and  circumscribed  growths  within  bones,  not 
independent  of  the  surrounding  bone. 

3.  Exostoses,  processes  of  various  grades  arising  from  the  surface  of 
a  bone,  not  of  traumatic  origin.  The  ivory  exostosis  of  the  skull,  or 
the  ossifying  ecchondroses  at  the  ends  of  long  bones  serve  as  examples. 
It  is  difficult  to  separate  from  these,  conditions  such  as  myositis  ossifi- 
cans, in  which  bone  gradually  replaces  set  after  set  of  muscles.  This 
last  should  perhaps  be  considered  as  an  example  of  the  following. 

Metaplastic  Ossification. — This  is  an  alteration  of  some  part  to  bone, 
accompanying  inflammation  or  senile  changes  in  a  tissue;  examples 
are:  (1)  the  "nders'  bone,"  where  bone  is  laid  down  in  the  adductor 
muscles  of  cavalrymen,  from  repeated  trauma  of  the  muscle;  (2)  the 
like  case  in  the  deltoid  of  the  infantryman,  from  pressure  of  the  rifle;  (3) 
in  the  choroid;  (4)  in  the  pia,  after  inflammation;  (5)  the  bony  plates 
developed  in  the  dura  are  even  better  examples;  (6)  in  the  heart  valves 
and  arteries;  (7)  in  the  lungs;  (8)  in  old  pleural  and  pericardial  exudates, 
where  bone  formation  often  follows  calcareous  infiltration;  (9)  in  various 
tumors — lipoma,  fibroma,  etc. 

Odontoma. — Pure  odontomas  are  rare,  and  odontomatoid  conditions 
commoner,  the  growth  not  being  independent  of  the  cement  substance, 
of  the  dentine  or  the  alveolar  periosteum  of  the  tooth. 

Bone-marrow  Tumors.  -Myelomas.— The  m\eloinas  are  tumors  of 
one  or  more  parts  of  the  bone  marrow;  morphologically  they  are  like 
the  sarcomas,  but  they  are  not  malignant,  do  not  form  metastases,  (lo 
not  infiltrate;  they  are  m-de  up,  not  of  cells  that  have  become  undiffer- 
entiated, but  of  cells  that  at  their  highest  development  are  of  a  relatively 
simple  tyi)e.  Hecause  the  tumor  tissues  do  not  depart  from  the  type 
of  the  original  bone-marrow  cells,  the  m\  elomas  are  typical  blastomas. 

The  different  elements  in  the  bone  marrow  are  these:  on  the  one 
hand  the  cells  directly  concerned  with  the  bone— the  osteoblasts  and 
the  osteoclasts  (or  myeloplaxes) ;  on  the  other  hand,  the  erythroblasts, 
megalocytes,  myeloblasts,  and  lymphohlasts- the  mother  cells  of 
red-blood  corpuscles  and  leukocytes.  The  cells  of  these  two  orders, 
widely  divergent  in  kind  and  in  function,  can  give  rise  to  corres- 
ponding tumors,  and  not  oidy  this,  but  each  kind  of  cell  can  give  rise 
to  its  own  overgrowth.  If  we  realize  this,  an<l  ajiply  the  principle  that 
each  kind  oi'  tissue  can  give  origin  to  three  orders  uf  growths,  vix., 
(1)  typical  blastomas,  (2)  atypical  blastomas,  and  (3)  blastomatoid. 


:Mi%^\iiaeMmi^'^mr^'M- 


MYELOMA 


237 


.liffuse  ..verKrowth,  we  can  reduce  the  various  overKrowths  of  bone 
marrow  to  some  show  of  order. 

2/>jc«/  fi/„,<on^a*.--The  Oiant-ceUed  Myeloma  {"Ginnt-cdled  Sar- 
ama  )  -Ihese  grow  locally,  oftenest  in  the  marrow  of  the  lone  bones 
or  of  the  jaw;  they  may  be  of  periosteal  origin,  as  in  the  gianLeled 
<I>..I.s  of  he  jaw;  they  grow  expansively,  causing  absorption  oTur 
roundmg  bone,  are  vascular  anr!  do  not  form  r«.La...,,  save  b  the 
cases  where  sarcoma  spnngs  up  in  a  hitherto  benign  growth;  they  do 
not  '•eour;  nor  do  they  require  to  be  very  "wi<lely"  removed     Ilitt 

E  '■;  t'  ^'"^''  V^'  *T"'  '^  ^"™'^'^  "f  «hort  spindle  cells  S 
.1  roblast  type    sometimes  polygonal,  and  giant  cells  kre  abundant 
Ihese  gmnt  cells  are  the  "typical"  overgrowth  of  the  myelcXes 
l.o..y  spicules  and  lamelhe  may  grow  in  the  tumor,  although  the  more 

.  ndant  the  gmnt  cells  the  less  likely  is  bone  formation  to  o"ur 
u  I      iuS""    ''''*^''""«*""«  '^"-th   (sarcoma)  may  supervene  in 


.'""^>'  M,./o,„«,.     These  are,  of  course,  the  sarconuis,  wlml,  mav 
i-    (.    pnmanly  or  (h)  Irom  typical  blastomas.  such  as  the  alW, 
II    !       '>'«/tomatoid  overgrowth,  such  as  the  following : 
l!la.sfow„to„l  Orergrouih.~Myelom&toa\a  (Myelovm  Mnltipkx)  -This 
a  I-nihar  form  of  growth  th^.t  affects  the  ret!  marrow  of  bones,  such 

K      ertebra.,  nbs  or  cranium,  converting  it  into  a  .lark  red  or 
■  Hl.-^-ray.  or  gra,    h-yellow  tumor  mass.    It  is  a  primarv  multiple 

.-.  arising  simultaneously  in  bones  widely  apart;  at 'times  the 
,"    's  are  soft  and  j.ulpy,  at  times  firm;  they  mav  project  up  to 

urtob;;'  *';.'V»-""«^eum    and  fractures  are  thus' common,  or  in 

Mrtebne,  distortion.     There  is  no  sharp  definition  to  the  areas 


23S 


PKOdRESSIVE  TISSUE  CHArOES 


of  hyperplasia.  Yet  with  this  progression  thi<  m>  ith  remains  con- 
fineci  to  the  hones,  and  there  are  n«)  met.  stii  iS  in  lymph  nodes  ()r 
elsewhere,  ("linically,  there  may  be  fever,  pain,  nnii  Nc-vere  inemia,  with 
albumosiiria.  Some  of  the  names  umler  whiih  tlk  u  iiarkable  condi- 
tion has  been  known  are  mahgnant  osteomyeHtis.  myelogenous  pseudo- 
leukemia, sarcomatous  osteitis,  lymphadenia  ossium;  and  our  conten- 
tion is  that  even  "myeloma"  is  incorre't,  in  that  it  is  a  myelomatoid. 
Histologically,  there  are  the  pure  cases  in  which  there  is  no  cner- 
growth  of  the  myeloplaxes  nor  any  indication  of  the  osteogenic  ele- 
ments t>f  the  Ixme  being  implicated.  The  tumor  cells  are  derived  from 
the  cytoblastic  elements  of  the  marrow,  and  are  myeloblastic  or  lympho- 
blastic in  type;  this  means  that  we  may  have  h)calized  blastomatoid 
overgrowth  of  the  lymphoblastic  elements  of  the  marrow  without 
leukemia. 

Myelogenous  Leukemia. — The  cell  growth  in  the  above  is  local,  but  we 
have  similar  diffuse  overgrowth  of  the  bone  marrow  with  at)undant 
discharge  of  the  cells  into  the  circulation— myelogenous  leukemia. 
Here  there  are  in  the  blo(Hl  great  numbers  of  large  mononuclear  cells 
with  neutrophile  granulaticms,  coupled  with  the  presence  of  increased 
eosinophiles,  "mast  cells,"  and  normoblasts.  The  ordinary  red  cells 
are  reduced  in  number,  the  white  cells  greatly  increased,  and  the 
myelocytes  may  be  one-third  or  more  of  the  total  white  cells.  The 
bone  marrow  is  seen  to  show  hyperplasia,  and  is  reddened.  The  main 
elements  present  are  myelocytes,  nucleated  red  cells,  and  numerous 
cells  with  eosinophilous  granules.  The  great  enlargement  of  the  spleen 
is  not  primary,  but  is  clue  to  an  accumulation  of  hloi<d  cells.  Some- 
times in  the  liver  and  kidneys  there  are  tumors  due  to  active  growth 
of  the  myelocytes  outside  the  capillaries;  in  fact,  there  is  an  overgrowth 
of  the  '  ieukoclastic"  elements  of  the  bone  marrow,  sometimes  confined 
to  their  natural  site  and  at  times  elsewhere  in  the  .,.)dy. 

Chloroma.— This  iM-culiar  tumor,  which  is  multiple,  affecting  the 
bones  of  the  face,  especially  the  orbit,  the  skull,  the  vertebra',  and 
more  rarely  the  ribs  and  marrow,  is  characterized  by  a  striking  greenish 
or  greenish-yellow  tint,  which  fades  as  the  specimens  are  kept;  the 
pigment  is  said  to  be  a  lipochrome  but  this  is  not  certain.  The  tumor 
is  a  medullary  overgrowth,  associated  with  which  is  a  leukemia  in 
which  the  prevailing  cell  is  of  the  myeloblast  type;  evidently  this  is  an 
aberrant  form  of  myelomatoid. 

Lymphoma  and  Lymphomatosis.— It  would  be  unwise  to  plunge 
into  the  vortex  of  tiie  nimierous  terms  employed  to  describe  the  various 
lynii)homatous  states,  and  to  lay  down  what  seem  to  us  the  right 
interpretations  of  these  various  terms.  We  prefer  to  state:  (1)  that 
just  as  we  recognize  that  the  lymphocytes  and  the  leukocytes  (the 
polyinori)honuclear  and  eosinophile  cells)  have  distinct  origins,  so  we 
have  distinct  series  of  blastomatous  and  blastomatoid  overgrowths 
originating  from  the  tissues  that  give  origin  to  these  two  orders  v\ 
cells;  (2)  that  just  as  among  the  c:vergr«)wths  of  fibroid  tissue,  there 


L  YMPUOMA  -llODdKlS  'S  DISEA  SE 


Xid 


t    m  al  ftbr„n.a  a.ul  farther  t..  atypic-al  sarc...ma.  so  lu-r.  i;  u,  il"      c-al 

"••^-   n«'t^spec.fir-lyniph,K.ytes   (lyniphohlasts)   an.l   vmm',W, 
t.-ue  cells   (hbrohlasts).     Tumors  .lerivell   from  thes     spS     Al l" 

•liiir*;^":;.""; "'  ^'t  "••  "^"^"'^^  ^'-^  Kiant-c.eii.:rmy:i,:;" 

.'ii«l  tht   \arioiis  diseases  due  to  overgrowth  of  the  invelohhsfs  nn.l 
.">.'I.K-ytes.  namely,  myelomatoi.l  (mjeloma  multiplei"    3 'enou 
l.uke,„,a  an,l  chloroma.    This  leaves  us  free  to  ,ieaU it    the     m n 

He  i;;e,l3       '  *'""'  •"  *'^  '""^^  ^'""'^  ^"  *h.;se  of  lymphoid 
KLmsS^Jhifr'"'*"*    ^^•'»'"P«':«'>le    with    ehronie    inflammatorv 

it.:ss-;-;sii- ^-^^^^^    -- '-  --- 

w.'il.VMJTh'.f"*"^  (c-omparable  with  cheloid).  I„  the  last  group 
-!<.'  .  \Mth  eases  where  a  known  irritant  is  the  cause  of  the  ivmnh 
«rpias.a;  here  w-e  have  a  hyperplasia  of  the  same  sor    v  1  enthe 

;:;:.;^::u;i;;:^iS:'" ''-  ^""'^^'  "•---"•-  -  --  — 

I  li«'  ly.nph-node  groups  «,f  the  b«Kiy  are  successivelv  enlarged   often 
r    mng  w.th  the  cerv  cal,  and  finally,  the  spleen  follows  S    tZI 

t;;  bT^^r^r'''^''"''*""  •"  r ^-"^  ^^•''"^'  -'•-vtomieally  node,  a  : 
Mribe.l.     1  he  lungs  reman,  free,  and  the  bhxKl  shews  no  nr..- 

'  fh^Stf""'''"'^""''-''  *'-.  ^'---ters  are  .liHVre.:;  fZ. 
s=  rn  ,  Vl  t  '  •'''^"'■'  "•'  "^"'  "*  '"filtration,  as  occurs  in  hmph.n 
.r         :;       "  rr^l^r*!!!:''! .r-T-^t''- -  —  i-  the  pre^'ious 


<T|1 

'I 

..r  I 

tin, 

!"■' 

ill  ' 

■| 


d. 


Ill    iiiii  ■!  r-.l..f:       -e      ^  . f'"""'.  "-""^iiiis  111  me  previous 

'yZ^J^Z'"'"'  "'^"''  "•'"^*'™  '"  '"^^  lymy>l.o4t..  an.l 
I.,  same  characters  are  foun.l  in  the  spleen,  there  being  no  excess 

'^i         ornt    the  ^s"T  '^'    r^^^'"^''^^  ^"'"«  '»"•  •'•-" 
.     iron.  I  tlu    \essels.      Ihesc  collections  are  provided   with  a 

"    ".  ...  connective  tissue,  and  do  not  infiltrate,  thougl     he    m.v 
'I.on  and  cause  to  atrophy  the  surrounding    issues      We  hT^^ 
'  '•  a  l.mph  h!,peri>Uma  mid  m,f.  a  mcUu^tasi,  ' 

"narked  contrast  between  the  involved  no<les  and  spleen  on  the 
:      ;.;      .  It  ^^^'""'""'.v  "-"'vH  organs  on  the  other,  stronglv 

nt     in  thettir  "ir  ''"'''"^  "'*''  '•^"*'"^'t"'"  "^  the  lymphoid 
i^,  m  tla   other  with  compensatory  hyperplasia.     It  has  been 


240 


I'ROdHKSiUVE  TISSiK  CHANGES 


til  i     ' 


% 


njperplasia,  fo  lowed   In-  exhan.st.....  or  atn.phv  as  tlu-  connect! 

ion     ''.nl!  T  ''''  T''^  '""'"  "^"'>'  ^fie  results  of  chronic  irri 

iLl^hiJo  T  \       "''f  "^^  *°  ""  "'"-^cogni'-ed  irritation, 
.i.  Lymphatic  Leukemia    Lymphocythemia).  — There  mav   l>o  o^ 
developn^ent  of  typical  Ivmph  tissurthe  r;ticu[urth7^n.ts  a 

tJie  cells  being  (levclojM'd  prop 

*•  tionately— a    real     lymphomat( 

overgrowth.    At  times  this  is  i 

stricted   to   the   spleen  or   cert« 

groups  of  lymph   nodes,  at  tim 

more   widely   developed,  even  i 

fecting  secondarily    the  liver  ai 

other    organs.     Of    inflammato 

overgrowth    the     indications    a 

slight;  the  capsules  of  nodes  mi 

by  distension  be  thickened,  but  tl 

reticulum   shows  no  correspondir 

overgrowth.     The    hvperplasia  n 

spccts  its  boundaries  and  shows  ri 

signs  of  infiltration.    This  can  exi; 

without  escape  of  the  lymphocytt 

into  the   bl<H)d,  a   lymphomatosi 

without  lymphocytosis;  only  whe 

an  excess  of  lymphocytes   appear 

in  the  circulation  do  we  have  tni 

lymi)hatic  or   lymphocytic    leukc 

inia.     It  is  conceivable  that  soni( 

cases  go  part  of  the  way  and  ther 

lvmnhr,r.v  f !,«»,;„     r'  i    r  ^'^""^l'^<''  '"^   ^P'^^nic  tumor  with  temporary 
i\mpnoc\tliemia  which  disappears. 

kimw^^fr*  ^rr'^'^'f  ^''  "'th'typical  fibroma).-By  analogv,  we 
it  s  o  c^  ./ '"'rffi 'TJ^"!"  ':"'■'**'•  "'*'"'"«•'  '•'-ported  cases  are  few; 
plS^ofT^ymS^  "■^'"^"•^'  '''^  *■"'"  --^-'i-i'^yP- 
coLfn?"!?*^  Lymphoma;  Lymphosarcoma.- Since  the  lymph  follide 
aC  with  Th  •«  T  ^'^f"  ^"'  "''^''''  '■''''^'  ^"'l  endothelium, 

severe  IflL  f^'"^''  Ivmph  cells,  it  is  evident  that  there  mav  be 
celled  .to  n  fTf  «"^'"«ting  from  it- round  celled,  spin-lie 
••ndistin..?;  -  ^  """/^-^'^'''f^  ««rm»s  of  this  onler  may  be  histologic,  11  v 
indistinguishable  from  lymphosarcoma,  and  the  cells  of  such  a  tunior 

tTsne  nrJ       1    "\^  ''T^'°"  ^'""^   ^  differentiated   connective 

tSe  n^if  '•^-  T'^^"™''  ^^^^  ^^'  ""*  S'-^^tly  departed  from  the 
t^pe  ot  Its  original  tissue. 


N  mon  o    rn|ar«,.,l   |j.„,ph   „„,,  ,,„„.   ^^ 
o     Ho,l«k>n,  dm.aso   to  .how    v„ri.,u3  or.l.T, 
of  -eh  prc.«,.,„,  ,„a„y  of   ,he„  ^f  |,,i„.,i^.^ 
mflammajorv   ..v,«...    a.  larg.-  .mlullulial  rHI- 
6.    fihrohlast,     r.    0(Jsino|))]i 
lymphocyt..;   e.    pol> nuilm, 
niiTsion  lens.) 


'/.    oct'aMinnal 
iikiirytc.      (Ini- 


recede,  ther-   b» 


ing. 


>nnect .  \  e 


LYMPHATIC  LEUKEMIA-LEIOMYOMA  241 

AM  these  .  u  ,s,ons   ,t  will  be  see...  fall  into  tl.rt^  mni..  classes-    (U 

III''  sple.i.c  e,.larKe,..e..i  may  W  the  o..lv  sic..-  there  m„vK        '^ 
|.anyi.,R  seco..,lary  a,.e.nia.  a..<i  cirrh,,s  sof  the  I  ver  (Zti-^Hr''""!" 
;;r  .t  ...ay  l,e  familial;  ..r  the  sple,.ic  Jnrt.^^.^Z'frlL^':;^ 

•rythrocytes.    EndotheUal  splenomegaly  {(Ja.chrr',  tyi^.l^  ra™ c  m 
.lit...,.  ,.,  wh.ch  se.u.ral  e..IarKeme..t  of  the  splee,.  is  assoeiattnl  with  „" 
rnuarkable  overgrowth  of  the  e,..lotheliaI  cells  li..i,.;  tl'spl^^   inusts 

.Noth.i.p  .s  ki.owii  alM.iit  the  causatio.i  of  either  nf  fh«...  , ' 
;  ...K    Banti  called  atte,.tio..  to  the  fJ^J^^L^l^^S^^ 
'  MTc  ,s  c^ulence  of  act.ve  breaking  ,|own  of  the  rer«  c,,rpuIcE  n  t 
>|.l.n..  w.th  accompanying  anemia  an.l  icteroid  state  whSmiv  be 
r.™re.l  from  completely  when  the  spleen  is  extirpated  ' 

Myoma  (Leiomyoma).-The  uterine  fibromyoma  or '^broid  "  is  the 
-"•"mo.,est„f  tnmors.     \-ery   freqnently  thev  are  multiple    exTst.^^ 

-  "'fmes  ...   arge  numbers,  a,.d  in  situation"  («)  intTrsS'  (hu2 

I  .  i.Kulate      Ihe  ...dividual  tumor  is  sharpiv  defined    and   somn 
;!  ...ut  easily  while  others  are  firmly  anchored  hv  a  Suse  cap  uTe 

I I  .are  two  ^oneral  types  a..d  all  stages  ,.f  tra.isitio.i  between  t^hem 
1)  the  pure  .nyoma.  reddish  gray  and  softer  than  C>)  the  ''fihS'" 

.;-,«.    a  n.ost  white,  and  showing  the  watereSlk  ipp  ara..ron 
;...;  T-T  ""•'  '""•"fi^«tions  occur,  the  following  be  ng  se^i 
tla„jj,,c.tat.c  tumors. ...  which  the  bloml  vessels  are  greatlvdnate-' 

-  l>n.phang.ectat.c.  in   which  the  lymph  channels  are     istended 

'>.n  Trims,  hemorrhag.c;   (4)   necrot.c,  an  actual  liquefaction  nt 

'   ■;-  occrnng;  (.5)  calcified   so  that  the  mass  can  be  J  onlvl^  the 

^ii  tc  ;   '  K'''^^"t^*  ^y  fatty  orhyaHne  degeneration.   ^ 

-."       rfih,;.;:^'  Kra,les  ex.st  from  pure  myomas  to  what  are 

■      ui  h   ItL?      ;•         *"  J>eg.nner  generally  finds  diflSculty  in  dis- 

St.  ?  ^'^^»es.  but  if  the  nuclei  be  exan.ine<l,  it  Si  S 

•      e    f  m,  Tl"'  '''T''^^'  *'««»*■  «re  short  and  spindle  shaped 

.  f  muscle  larger,  longer,  rod-like,  and  with  blunt  rounded  S' 


242 


PROdRESSIVE  TISSUE  CHANGES 


Cut  traiisviTSfly,  tcM),  tli«-  coiiiuctivf-tissm'  micleii.s  lias  a  nakwl  appear- 
ance, while  the  nniseU'  luiclciis  has  around  it  a  fair  amount  of  cyto- 
plasm. The  small  tumor  is  pre|Mfn(ieratinjfly  muscular,  the  larger 
fibroid,  a  change  due  to  the  fact  that  the  relatively  poor  l)loo<l  supply 
causes  the  gra«lual  ett'acement  of  the  higher  tissue.     These  tumors 


Kiu.  K5 


Section  ii(  portion  of  h  pure  niyoniu,  nliowinit  the  e'haraiter  of  the  nuclei  and  the  appcariiDCG  of  the 
ccIIh  <'til  longitiKlinally  and  trausveraely.     (I'erli.) 


SeotioD  from  a  uterine  (ibromyoma  (high  magnification)  to  show:  a,  muacle  rells  with  rod  lilc; 
nuilei  cut  !onKitudiniill>  ;  h,  a  bundle  of  muscle  cells  cut  transversely;  r,  fibrous  connective  tistue 
around  bundle,  with  (i)  spindle-like  nuclei  of  the  same;  </.  a  capillary. 

are  essentially  benign,  grow  locally,  and  sometimes  throughout  a  long 
period  of  years;  clinically,  they  are  often  associated  with  mem.rrhapia 
or  metrorrhagia,  the>-  obstruct  pregnancy,  and  the  demand  fo'  tluir 
removal  is  by  no  means  so  negligible  as  their  histological  nature  might 
suggest. 


^^ 


:!mmff^^j3M 


LKIOM  YOMA  ~RIIAHIH)M  YOMA 


t..  su,,,L.  that  LVI ndZr ii;  ^    ';■  ""'"'  "''T^  «'"«i'Jerable  reason 

arr:    CI )  other  parts  of  i\u  IJT     •  ''  *'"'''  ""'  ^'^Pt-f'aH.v  seen 

-•!'  '!'<■  skin.  wluTe      A-  „T     ^-sp  nully  the  stomach  and  intestines; 
"•—.nee  ii.  oth     p'^s "  th;";:^^'.""  wf  f  •  r  "^^^'"«^"'  -^h 

'>  •--'«•"■<«  it  seems  tr^ S^J^X'-  l^.i^^  JS. ^-'^ 
TYPICAL  HYUC  TDMOBS    OF  MESOTHELIAL  ORIGIN 

Fia.  S7 


ton 


musrle  fibres  from  a  rh.iM..r.„o~.,  ^,  ,v- 

^  ^  **^"'   "oP'-.i,..-.     (Wolfensberger.) 

lomifl,  generally  small  and  capsulated,  yet  stUl 


•*& 


•JM 


ru<Kiin:s.'<i\  !■:  nssch:  <n\\(-h:s 


ill  an  1    "A !  en    iiii\ril  tiiiiiors  iin-  «iiiiiiin>ii;  Hpart  frntii  this,  Imwrver, 

ll .1      ill  ;ir(iiN  svliiTf  striiitiil   iiiii>ilf  i^  ni>rinjill\    pi   M-iit,  ^mh 

a-  the       ;irt,  the  txtr<'iiiitif>.  the  iiiUcs,  thr  <»rl>it.  i 

III  nil  ;  II'*'  ciiscs  the  Hlin's  art'  of  cinltrximic.  iiniifrfci'tlv  ilill'i  r- 
« ntiiiitil  iijitiirt',  soiiictiiiH's  >li(iwin>r  only  lnii>;if uiliiiiil  ^rintion,  «>r 
traiisvcr  i-  strii  ti  >ii  nf  oiil;  a  part  of  the  crll,  aini  other  >  liiructt-rs, 
all  of  wiiitli  |M>i'it  to  the  likcliho...!  that  they  arise  from  etfl  rests 

In  s..r  of  t'  .  ic  tiiniiir>  the  eells  are  eomparative'  imiliH'eretitiHteil, 
and  l''  e  u  .turally  liifKciil*  to  (listiii>;iii>h  froii      inuniis;  in  faet, 

niali>;i.i.ii  ha'i  omyoniii  lias  t/een  n-jmrted,  '  "Imh  the  iii'tastases 
sliowfil  %!ri;iii'ii  iiisele  elements;  ill  hotli  flu- -e  last  foru-  tlier»'  is 
ronsif'  '  (i>l'-  IW-t'iImmhI  »liat  the  tiiinors  arise  from  sarcobUau.  lifhouuli 
tlie.v  II    ;    hi' e  !)ri;,'iMiite<!  from  cells  of  a  yet  e;>  litr'NiM". 


TYPICAL   HYLIC    TUMORS   OF   EPIBLASTIt     JRIGIN 

The  Neuroblastomas.  •  >  il.\  such  tmnor  as  i  mtaiii  nerve  cells 
should  he  classed  a.>  neuromas;  further,  if  tlu  -e  he  inrve  fibres  in  a 
tumor  whieli  are  in  ckimh  ction  with  a  !,cr\e  dl  outride  the  tumor, 
these  iire  not  iiidepemi     t,  and    o  fiir  ji    tlu',\     re  concerned,  the  tumor 


t^X  ^S 


("fll«  frnin  ■.         iiuti  ;itii!  :i     tjjliif  rijinf   m-tU'  I'liiia  'v!   ! ;  iif    ni'iiriTii:!).          ii'i-ti\.'ly,    lln-           -r 

trcint    ihf    Hiicrui     tfifK.n.    !ii»'    Lint"-    lit. in    llit-  ro(H-rn.'ll.:il    n'^inti    :»t     th-            ■■!    i»f    the    [ttil" '•     ' 
lit     Hrh.-kr  I 

is  not  .    neuroma.      \ltli<iii>;li  i  'nie  neuroma  or  liiii.^'lioi'Un         i'* 

one  of  the  rarest  of  tumors,  .\  it  ni.  4  he  remeuiif  red   li            <r 

I  ..ii^titiieiiT-  oi  tilt'  nerv(.u.-,  s.   :.  ?,;  ,,rip:iii,.te  fr    -.  '''■■    -am-              "f 

cells  a >^          lie  neurones,    .lust  »- jii  the  "\  arv  th    .iii  tlpi  c;  (is  and 


% 


\El  /»t.\fA 


2  IS 


--^'^'^^^^^^^^ 


<i\ 


<{  it'U.    '11 


csi- 


;,"*■•■    ■    "    !'"•"«•'"•■    H..s;    Ci,    ,|„.  ,„.„ 


ru>;li)i  ( (.||, 


'   '"'    ••l*^'i.lymiiJ  nils  iinintr  tli«-  can,.       f  t\  ■     i r "' 

,       ,1  ;         *•"»'»»  "Muiirniua,   or     uiirocxtdini'    r*\   ♦!.        !• 

'■■     '■■'  •'""•'^""  '"".  »'kI  (4)     lu.  ,H.,.nnon,;;  •     ^^   ""    ^'''""""^ 

Hiiors  ■>    lur 
'  ..iiiip!  ,  IV,,  „  f 
ill  (oii- 
'>iitain 
'■•iiijriion 
Koiind 
levdoi 


•  1 '  ■'"  iim,   itiKi    (■ 

Meuroin*.     Tru«-  Neuromas 

'"■I-    i.'    ".   f||.    al.     .„„.„,  f.,r 

IM-lltjl!:,      ,f  tin     ,ldr.:     il,!,, 


Hl.n 


ills  I     fi,  tyjje 

11^,  v<ifli     ,(),„ 

tK  ill  |ii     thf 

'itfil  an.    Mali, 

"''  part 

trut     .' 
Im'. 

'■riuT 

-Tt'irai 

ii  ■  ' 

til 

'a 


"        itllMM 

■  it"'drif 


-I/O  have  iM-rn  f«)iiii,| 
-<lar  ploMis  and  tlic 

^m.  gg 


•III  ,,f 


^•Kr. 

S 

..I    li^ 
t-'iiiial  orijjii, 


;iiiii  f!i, 

Ml: 


■oma  is  fi.riiK. 
ofriH,  ..lor|.<ar-shapc( 
^laiuriiutiiiilik.'aiialvtM)- 
ninnin^r  from  wiuVI,  ,,,„ 
i>i  fl  by  :<pc(ial  staiii>  fiiu- 
'OS);  (Ifspitc  this  fact  siich 
toiind  to  nWv  ,„,.ta^i  tscs, 
>•♦  arc  practically  iiciirosar- 


ih 


til 

111,1  ■ 
til.fil. 
iiiiIk  I 
f'riiii 


'ilc<      rnputation  neuroma  is 

••••"la.    H  it  the  proximal  end 

"Tve  i   conifs  -wollcn  into  a 

"lavs,  oft,.,,  stronjily  united  hv 

to    Its    siirronndin^'s.      'I'hjs 

""^'^ts    of    h„„dlcs  of    „,.rvc 

^''irviiiK  iip<.n   themselves,   and 

''   "I    III    an    over>:r(»\vth    .  ;    the 

"<i<'-  and   perinenrimn.    'I'he 

*''"-||>  generally  lack   me<lullarv 


a  hi 

lliin 
III  i' 


M.ll  in.,r,.  ■•..„,l,rv„„u."  n.-ur,,,  yl„mn 
fn.m  a, .l,.l,l,  „«,.,!  «„,,.„  „..,„„,  \^l"^ 
Iil.«ton  a,„l   W„|l,tt,l,  ,    Thel,a     liko  ,.,- 

ra«K,.„„.„,.,f  ,,,..,,. II,  «.i,h.-..„,ralm.ril,„ 
.l,aru,.t,.n«.,c.,f, arly  ,,„k,.    in  ,(„.   d.- 

-    ""t   a  true,   tnmor   forma-    <^^~/h.Vh;:;7'"-'*-   '^""'""■"• 
It    an    aberrant    regenerative 

--::ol'";";r;";,,;!  ;,;:;'•;■■;  ^-^--r  *''"^  ^''""-  ^"''•^--''ip  t" 

'"'•'".  ...nd  ,  ')      I,  ,   .     7  "l"'"'"t  <!"-  M,t  follow  all  eases  of 

\|i:d,i!it<   .•..:!'"""  .'*  '"'^  •""■•■  «l«-voIo|H.,l  and  l.c,,  r. vcd 

-i-rve  sLr'      ^'■'■'"•'  '""""■  "•  '•"•"•  "^  ^'"'  ^'•-'•b  -M.oscd  end 


246 


iP 

|"»;i- 


PnnauEssix  t:  tissue  chancfs 


Glioma.— The  ^lia  <t'lls  an-  small,  round,  tr  oval,  with  a  single  I 
nuclfus  and  u  small  anutunt  of  protoplasm,  having  radiating  fine  pro-' 
cesses  riuuiing  from  one  to  another  in  all  directions.  These  processes,  j 
like  those  in  ordinary  white  conn»'ctive  tissue,  are  probably  true  pro-i 
cesses  of  the  cells  that  later  may  become  separated  and  independent! 
as  fibrils.  Tumors  formed  of  these  glial  cells  are  found  (a)  in  the  brain,  I 
(b)  along  certain  cerebral  nerves,  (c)  in  connection  with  the  retina,  i 
and  (r/)  over  the  coccyx,  from  the  remains  of  the  neural  canal.  In  | 
s\ringomyeIia  is  found  glial  overgrowth  that  is  to  be  regarded  rather  I 
as  gliomatosis  (gliosis)  than  as  glioma.  (Jliomas  are  hard  or  soft;  the  I 
former,  as  found  in  the  ventricular  walls,  are  well  define*!;  the  latter  ■ 


KiQ.  90 


Ciliiini:i;  riuiiicrous  neuroglia  fibrils  surromid  the  ri-lls  ami  run  in  all  dirpctions.     (Mallorj.) 

are  dift'use,  infiltrating  growths,  not  cajjsulated,  very  vascular,  ami 
liable  to  be  the  scat  of  hemorrhages.  To  the  naked  eye  they  are  areas 
of  greater  translucenc>  than  the  surrounding  brain  tissue,  with  a 
bluish  tinge,  and  pidpy  by  reason  of  the  glairy  fluid  in  the  matrix. 
These  last  are  found  in  the  cerebral  hemispheres  and  the  corpus  callo- 
sum,  and  may  be  of  large  size,  replacing  and  compressing  the  bnuii 
tissue.  Neither  hard  nor  soft  forms  give  rise  to  metastases;  and  recent 
studies  go  far  to  jmne  that  many  are  strictly  forms  of  gliomatosis 
rather  than  gliomas  arising  fn  m  a  single  focus. 

Retinal  gliomas  show  more  definite  signs  of  nmlignancy,  lM)tli  in 
their  capacity  to  infiltrate  and  to  give  rise  to  metastases.    They  are 


II 


Fig.  91 


GLIOMA— SEURl  SOMA  247 

Mnall,  soft   gray  masses  projecting  from  the  retina  into  the  vitreous 
"a>  .nvade  the  se  era  an.l  extend  into  the  orbit;  or  filling  the  bdb 
eumorrnay  erode  the  cornea  and  project  oteniall^t  a  fungating 
...iss.   Histoiogieaily,  they  are  forme.!  of  small  cells,  without  processes 

TSenrt:';""""'  l""'  -^'-^'^  ^""'  «'-'-^  may  or  maTnot 

•pneiance      Tn^'Tiv'"'":  "7?"^^"°""t  «"KRests  a  perithelioma 

r    LI.    •  n  "  iuhhtion  to  this  grouping  of  the  cells,  there  are 

gest  the  retinal  cones.  These  retinal 
gliomas  are  formed  of  cells  little  dif- 
tmntiated,  and  are.  we  hold,  properh 
gliosarcomas. 

In  attempting  to  determine  the 
itioi(,gy  of  gliomas,  we  are  helpe<l  bv 
tlic  fact  that  in  the  newborn  tiiere 
arc  occasionally  to  be  found  micro- 
scopic areas  formed  of  glia  with  in- 
(lii.lefi  nerve  cells.  Since  thev  are 
'">i"d  .;,  the  white  as  well  as  the  grav 
matter,  they  seem  t.,  be  misplaced  in- 
fliisioiis  or  overprutiuctions  of  nerve 
tissue,  evidently  developmeiK II I.  This 
and  the  liability  of  the  voung  to  the 

-  Pithelium  of  tlfe  „at nre  Tttt  "'.  '1'  r  '*'  T  '^'  ^^«  °"  *«  f"™ 
■Hurones  and  S    cells  dlt    ^V"^"''  '"'^^  *''*'  "^'"-al  canal.    That 

--r  o?  gliCatlHis  nair"'"""'  '''''  ^^'^^'"^  "^  ""  '-'"-"  '"  « 


fwclion  of  reUnsI  glioma,  showing  re- 
lationship of  cells  to  vessels  and  forma- 
tion of  "rosettes."     (Hihben.) 


1^ 


248 


PROGRESSIVE  TISSUE  CII.WOES 


that  interspersed  aiiioufj  the  fibroid  tissue  are  individual  nerve  fibres, 
and  this  relationship  has  necessarily  caused  a  ^reat  deal  of  debate. 
Regarding:  the  tumors  as  brought  about  by  overgrowth  of  the  peri- 
neurium, they  have  been  considered  fibnnras  and  wrongly  termed 
neurofibromas.  Others  have  recoj^nized  that  the  fibroid  tissiie  is  due 
to  a  proliferation  of  the  cells  of  the  sheath  of  Schwann,  and  believing 
these  cells  to  be  mesoblastic,  have  again  held  to  the  fibromatous  theory. 
It  has,  however,  been  fully  established  by  Kohn  and  Vero^ay  that 


Fio.  92 


-I 


Multiple  fihrimiiitoid  ovi-rgrowths  along  the  course  of  the  cutaneouM  nerves.     (Herejel.) 

these  cells  are  of  neuroblastic  origin,  that  the  growths  are  formed  from 
a  neurogenous  tissue,  and  are  derivtHl  eitix  r  from  the  sheath  of  Schwann 
or  from  precursors  of  the  .sam«'.  These  tumors,  therefore,  are  to  be 
descrilied  as  nenriimnns^  or,  more  aecuratt'ly,  as  neurinomatoid,  becauM' 
characteristically  the  tumors  are  multiple,  they  occur  without  shari) 
delimitation,  and  along  the  course  of  the  peripheral  nerves.  There  ni.iy 
indee<l,  in  some  cases,  be  a  coincident  increase  in  the  true  connectixi- 
tissue  elements  just  as  occurs  in  a  uterine  fibroid:  there  m«v  also  liC 


I "/""',  ii  nerve; 


sinew  i.r  fibre. 


CllOnWMA 


249 


Alon,  with  thJ;  S  ,  "  :  t*  Sr'"' ''  ^r'-"""t"-  '•'-•a;^t.rs. 
-t,.us  areas  i„  the  r  i„  uh  nina  \  ''r  1""'''"'  r''^*"'"'  '•^'  «'"" 
^.iretative  activity  i„  tl      ,,-,„.'  t  r'  "  "•'"''*'""  "^  Ki-'»'ral 

Fid.  93 


:;e,:r  ■;::,.- '/i;::^ -J- «;^^^^         n.  ..„,..,  ,„  „.„„, ,„. 


OP  HYPOBLASTIC  ORIGIN 


'^N°n*!°;^;^J^^^^^         ''T'  "'  ""'^'  "■•  ""  '">I«>rtarK.  which  renre- 

"'f'  r  ntial  substance  are  f,  m  ,    i  ^h    • '  T^"'"*;'''  \'^'  "  ''«'n">Ke..eous 

• '    ■n'al.nc.rmi  ow  h    fl^^^^  '"^ks;  nu.st  com- 

'""l>    'he  site,.f  the  ™    ;„irTl  r?""'  f ''*  ^'^'''""'  t''^'  '"tu'tarv 

^•^ ""    '"Irosis.  i.rth  "bone  ttllLT-  !^^^^         f  '^^"  spLemvoccipital 

"'  '1^    l-iisilar  arterv.  ^"'  "^**'"  '"t'^'ately  attachwj 


2:)0 


I'liOCRESSIVE  TISSVE  rHAXOES 


i 


ATYPICAL  HYLIC  TUMORS 

Sarcomas.  -While  it  is  logi.-al  to  discuss  the  atypical  tumors  with 
the  typical  tumors  of  each  tissue,  it  would  he  cumhersome  l.y  reas.m 
.,f  the  nudtiplicity  of  the  sarcomas;  they  are,  there  Ore,  here  dealt 
with  as  a  class,  the  members  of  which  have  certaui  characters.  Ihe 
term  has  primarily  a  histological  siguificauce  ot  which  these  characters 

'''Vhrsammms  are  richly  cellular  tumors  of  the  connective-tissue  t>pe, 
the  cells  hcing  vegetative,  imperfectly  d.tferentuited,  reseml.lmg    he 
emhrv.nic  mesenchyme,  and  developmg  a  characteristic  interstitu 
suhstance-the  "  hvlic"  arrangement.    This  arrangement  can  apply  not 
onlv  to  tumors  derived  from  the  mesohlast  (whether  raesenchymatous 
„r  mesothelial).  but  also  to  certain  tumors  (.t  epiblastic  and  hypo- 
h  astic  origin;  that  is,  .>n,e  atypiral  e,M.Uc  tumors  nrust  ahobere 
„aakd  a.  sarcomas,  .nd  artkely  i,romn,,  tumors  of  tra„sUionaIlcp,d,c 
charact  r.  are  also  to  be  considered  as  sarcomas,    ^uch  tumors  are  mhltra- 
tive  and  malignant,  hut  the  malignancy  depends  upon  more  than  the 
mere  form  of  cell  present,  for  two  tum<,rs  ..t  etiually  small  round  crlls 
nav  differ  greatlv  in  malignancy;  the  tissue  of  ..ngm  is  of  the  greatest 
mportance:an.l  it  may  be  said  that  the  more  nearly  the  cell  approache 
the  cell  of  embrvonic  mesenchyme,  the  greater  is  the  presumption  of 
malignancv,but'more  important  yet  is  this:  that  o    two  «uch  tumors 
the  one  that  has  departed  the  farther  from  its  adult  type  of  cell  to 
rl^ch  this  state,  the  one  that  has  "reverted"  the  more,  is  the  more 

"S'sarcomas  are  not  capsulated,  but  grow  peripherally  m.d  invade 
the  surroun.ling  tissues  by  growth  along  tissue  spaces      Ihis  leads  to 
progressive  destruction  ..f  the  preexisting  tissue,  '"»  ,  ^''^^''P^'"'    °' 
all  that  tissue  save  a  supporting  framework  around  the  vessels  and 
capillaries.    Thus,  the  tumor  cells  are  frccpiently  arranged  m  masses 
eparated  bv  well-marked  strands  of  cnnective  tissue.     J^  sareo.a 
cells  nnne  In  the  immediate  neighborhood  of  the  cajnlanes,  and  the  n  essts 
are  compose.1  of  a  single  ea.lothelial  layer  beneath  which  are  the  turn  . 
c  lis;  the  capillaries  are  wide  and  the  tumor  abundantly  vascular.    It 
is  pn.bable,  but  not  certain,  that  there  is  a  new  formation  of  eap.HaraN 
and  that  the  sarcoma  cells  grow  along  these,  just  as  the  fil>"     '-^ 
appear  to  extend  outward  among  the  growing  loops  of  granu  a     n 
tissue.     In  some  sarcomas  there  are  channels  that  have  "o  «ndot  e- 
lium,  so  that  the  blocKi  seems  to  make  its  way  directly  between     e 
tumor  cells.     It  will  thus  be  seen  that  hemorrhage  into  the  tun.    s 
"apt  t..  occur,  and  that  sarcoma  cells  are  liable  to  become  free  m  te 
blood  stream,  so  that  metastases  almig  the  blmd  stream  are  charactmdic 
of  these  growths,  and  the  lung  is  apt  to  be  a  common  site  o   secondarj 
sarcoma.    Of  course,  metastasis  can  occur  aU>  along  the  lympiw-     - 
so  that  involvement  of  lymph  no<les  is  not  diagnostic  of  carcuu-ma. 


-^  a 


SABCOMA 


2-)l 


Some  observers  consider  that  siireomus  possess  no  lymph  vessels  proper, 
liiit  only  oceiisional  spaces  iiml  (luiniiels.  Tumors  growing  as  rapidly 
iis  (jo  the  sarcomas  necessarily  present  ahuiidant  mitoses;  cell  inclu- 


Fiii.  »1 


I'ni.iarv  malignant  lyiiiphonm  of  stiiiimrh:    a.  prc<l(iininaiiiJH  laruor  cells  of  lymphobliutic  type; 
b,  amallcr  lymphocytes.     (High  poinT.) 


Fig    'J5 


iiiion  uf  ciDtrc  of  active  lymph  node  to  show  relationship  of  proliferating  "mother  cells."  or 
I'hiililusls,  to  the  lymphocytes  to  which  they  give  origin:  o,  lymphoblast*  of  largo  siie- 
.  iiipluxytes.     (High  niiiuuificaliou.) 


I'Hw,  signs  of  degeneration,  the  so-callefl  "sarcoma  parasites"  occur, 
■  Hit  nrc  not  so  freouent  as  the  correspiiiiding  ofciirrencc  in  carcinoma, 
'"'il  a  frefjuent  incident  is  the  wholesale  necrosis  of  a  part  of  the  tumor. 


2-,2 


rnnaREssfivE  th^svr  cnAsaEi^ 


Forms  of  Sarcoma.     Altlioiiuli  luck  of  ci-ll  ditlVn  iitiatimi  is  to  a  large 
extiMit  Hccoinpimij'd  hy  roti-ntioii  or  acciiiin'iiinit  of  iiicToasod  vegeta- 
tive activity,  yet  tlic  stages  of  uiuliHercntiation  or  anaplasia  are  not 
entirely  identical.    .\  cell  in  its  neoi)lasia  can  lu-ver  repriKluce  a  stage 
tlirongli  which  it  has  not  passed  in  its  normal  develo|)ment.    Thus,  a 
glia  cell  never  passes  through  a  spindle-celled  stage  in  its  development, 
imd  conse(|uently.  vegetative  glia  cells  never  pnKluce  a  spindle-<tlled 
.sarcoma;  again,  the  lyu.phocyte  is  a  smaller  cell  tluin  the  lyniphohlast 
which  i)rodi..es  it  (Fig.  !».')),  and  a  lymi)hosarcoi»'.a  formed  of  vegetati\e 
lymi)hoid  cells  may  he  of  a  larger  cell  type  than  the  adult  lymphocyte 
(Fig.  !t4);  it,  also,  niay  not  he  of  the  spindle-celled  type.     Only  those 
cells  which  in  the  cinirse  of  their  (normal)  development  i)ass  through  a 
spindh'-ci'lU'd  stage  can  give  origin  to  a  si)indle-cellcd  sarcoma;  such  cells 
ar:'  the  connective-tissne   ell  and  the  i)lain  muscle  fihre.     The  statement 
has  l)een  made   without    sufficient   justification  that  a  tyjmal,  fully 
ditlVrentiatcd  tissue  or  a  typical  hlastoina  cannot  give  origin  to  sar- 
coma tissue  i)ure  and  simi)lc;  to  say  that   this  process  cannot  occur 
is  e(iuivalent  to  stating  that  fully  dirt'eientiated  cell  arises  from  fully 
ditVerentiated  cell;  hut  this,  of  course,  is  not  the  case.     Kither  there 
are  undifferentiated   mother  cells  normally   present   from  which   the 
differentiated  cell  arises,  or  as  in  muscle  and  other  tissues,  the  differ- 
entiated cell  loses  its  si)ecific  features  and  hecoines  vegetative,  in  which 
state  it  is  ready  to  proliferate.     In  a  highly  ditferi-ntiated  tissue,  or  in 
a  typical  hlastoma,  cells  may  lose  their  sj)ecific  properties  and  hecoine 
simpler;  they  need  not  revert  all  the  way;  regenerating  muscle  fihre 
reverts  to  the  sarcohlast,   or  again  it  may  revert  all  the  way  and 
resemhle  the  primitive  mesohlast.     It  follows,  therefore,  that  ii  tumor 
may  show  any  stage  from  the  very  lowest  vegetative  form  up  to  the 
not  quite  perfectly  differentiated  cell.     lieing  imahle  to  function  nor- 
mally the   tumor  cell  actually   never  iloes  ac<iuire  perfection  in  dif- 
fv-rentiation. 

The  vegetative  types  of  cell  are  simjile  and  alike,  from  the  small 
round  cell  to  the  larger  round  cell,  to  the  oval  cell,  to  the  spindle  cell; 
thus  there  are  to  he  distinguishe<l  several  forms  of  sarcoma:  (1)  small 
round  celled.  (2)  round  celled,  (:5)  large  round  ccIIimI,  (4)  oat-shape 
celled,  (■"))  small  spindle  celled,  ((i)  large  s])indlc  celled,  and  (7)  niixcl 
celled,  which  last  we  employ  when  we  are  not  ahle  to  say  that  one 
form  of  cell  is  the  predominant  type.  Tliese  are  pure  sarcomas,  hut 
there  are  also  the  Intermediate  sarcomas  in  which  the  cells  have  not 
hecome  ahsolutely  undifferentiated,  so  that  certain  tissue  characteristic  s 
are  preserved  here  and  there  in  the  tumor.  As  examples  of  this  form 
might  he  mentioned  fihrosarcoma,  osteosarcoma,  and  chondrosarcoma. 
These  more  differentiated  cells  necessarilx  indicate  a  lesser  degree  -it 
malignancy,  and,  on  the  other  hand,  the  more  vegetative  the  type, 
the  greater  the  malignancy;  since  the  stages  through  which  cells  ])m^'* 
in  hecoming  undiifVrcntiated  differ  according  to  the  cell  concerned,  it 
may,  therefore,  happen  that  cells  which  look  alike  may  have  Iwconie 


ify 


II 


!!• 


^ir<S7c' -vxatAmj 


TuT, 


SARCOMA 


253 


s(.  through  much  or  little  undifferentiation,  and  thus,  t<;  rer<Bt,  the 
iniilinnancy  of  superficially  similar  cells  may  he  very  ditfereiit. 

Small  Round-celled  Sarcoma.— The  most "maligiiant  and  infiltrative 
growths  to  he  tV.und  helong  to  this  class.  The  cells  are  closely  packed, 
>tain  deeply,   and   ijossess   round   nuclei   with   little  cytoplasm;   the 


KiG.  07 


-iimII  roiiiul-.-i-lliil  sarcoma  frnm  akin.     (High 
iiacuilii-atiiin.)     (From  Professor  KK-I».) 


"^ 


ICuund-ocilcH  sarroma  intiitrafing  the  heart- 
wall.     (High  iiiaRnificaliuu). 


Fio.  !I8 


S.  D 


!•  iii.l-iclU.I  >!ir<-...na,  iiifiltratiuK  livi-r,  ailvanciiig  aiitig  a  portal  sheath:   V.I',  portal  vein; 
H  I),  liili-  (liiet ;  A.  II,  h<  palir  artery;  /..  liver  cells. 

iitiiil  rcticiilimi  is  at  a  niininumi.  These  growths  are  vascular 
''  .kIIIv  iiiulcrgo  hemorrhage;  metasta.ses  occur  hy  the  blood  stream 
!!i«'  iyinphatics. 

-*  cdK  .irc  cuiisidered  to  ari^e  from  connective  tissue,  the  growths, 
' '.  tH'irtg  not  unlike  a  (('liuiar  granulatitm  tissue;  it  may  be  recailed 


254 


PRnaiiKssivi-:  tissie  cuasces 


as 


thut  the  siinpU'  vcnotiitivc  iifiirohlast  colls,  us  seen  in  ii  retimil  surcoma, 
were  of  this  sort,  and  it  may  well  he  that  this  is  the  least  ditTerentiateii 

and  the  most  actively  vegetative 
»■<■  »•••  of  all  cells. 

,  The  ordinary  round-celle<l  sar- 

coma, siH'cified  neither  as  large 
nor  small,  is  merely  an  arbitrary 
group  whose  cells  are  of  any  size 
midway  In-tween  this  and  the  fol- 
lowing. 

Large  Round-celled  Sarcoma. — 
Although  evidently  relate<l  to  the 
two  forms  already  nientioneil,  the 
large  round-celled  sarcoma  is  quite 
a  dilVerent  tumor.  The  cells  are 
fairly  large  with  abundant  cyto- 
plasm, not  nece.,sarily  round  but 
sometimes  oval  and  «-ven  polygonal.  There  is  a  fairly  marked  reticu- 
lum, and  there  may  be  in  parts  of  the  growth  a  definite  connective- 
tissue  stroma.  They  do  not  destroy  and  cause  absorpti(m  of  other 
tissues  as  readily  as  do  the  last-iuuned  forms.  Such  tumors  are  often 
found  in  connection  with  striated  muscle;  the  most  active,  vegetative 
form  of  lymphoma  presents  also  this  kind  of  cell. 


I.nrKc  round-celled  siirroiiiii.     (HililuTt.) 


'•b 


Alveular  blunt  >pindle-rplled  minimui  (sH-ondarj  .  non-i.i«mpnted  growth  of  melsnotic  «ar  ■■  ma— 
or  clironiatnphnronia — of  skin):  o,  ci'll  with  two  nuclii,  roerntl.,  dividud;  6,  pigmcDt  contniiiing 
leukocytes  in  stroma;  c,  neptum  between  alveoli.     ( Iliith  power  ) 

The  Oat-shape  Celled  Sarcoma.--  It  Is  jjcrhaps  overcare  which  seek> 
to  differentiate  this  sarcoma  from  the  si)indle-celkHl  sarcoma,  but  in 


■as?.  >-^  *.-».•'« 


SARCOMA 


255 


(■(iiitrailistinction  to  the  lutter  members  of  this  ^roup  have  long  oval 
niiriti  lying  in  blunt  cells.  We  are  not  prepared  to  state  that  they 
(iri^jiiiute  from  any  special  form  of  tissue. 


Fio.  101 


Kiu.  103 


Spindle-eelled  aarronm  (rcrurrunt,  from  fon-arm) : 
Oiit-shape  celled  sart-oma  of  unknown  orinii,  o.  delirate-walled  blood   vessel  in  tumor.     (From 

(High  power.)    (MeOill  collertion.)  Professor  Klotl.) 


The  Small  Spindle-celled   Sarcoma.  —  The  cells  of  this  form  are 
rchitivdy  small  spindles,  15  to  20 fi  long,  with  oval  or  spindle  iniclei, 
the  ((lis  appearing  in  bundles  around  the  capillaries  just  as  occurs  in 
true  fibromas.     The   relationship  of   these 
to  coimective  tissue  is  so  marked  that  their 
xHirce  is  evident;  in  fact,  the  fibrils  which 
ncdir  ill  connective  tissue  may  be  found  in 
till -(■  tumors,  which,  compared  wiih  round- 
11  III  (I  sarcomas,  arc  far  less  malignant. 

Large  Spindle-celled  Sarcoma  (Fig.  103).— 
i  he  nuclei  are  large  and  clearer  than  in 
til'  last  case,  are  often  vesicular  and  the 
(1 11-  vary  greatly  in  their  size  and  shape. 
>i'iiie  arise  from  the  periosteum,  recalling 
tlu  large  spindle  cells  which  occur  in  the 
viint-cellcd  myeloma;  this  is  to  be  expected 
'"  i-,i(lering  that   both   originate   from   the 

me  tissue. 

i  t  will  appear  that  there  are  not  very  sharply  cut  distinctions  between 

•  ^iiilcrent  groups  of  cells  that  have  just  been  dealt  with;  this  is  due 
'lie  tact  that  undifi'erentiation  has  gone  on  to  a  different  stage  of 


Large  spindle-celled  sarcoma. 
(Ribbert.) 


".  >"%-■«.■  laHis. 


2.*)r. 


I'H(K!RKSSIVK   TISSIK  CII.WaKS 


!!■ 


li' 


c'«>iii|)lt;toru'ss  ill  i-iuli  casr,  just  as  tin-  Kriiwiiij;  ci-lls  attain  <litr»Tcnt 
(k'jtnrs  of  ilitfLTcntiatioii  in  tlu-ir  formative  procfssi-s. 

Intrrmrdiiilr  Ti/ixs  »/  Sdmnnii.  Fibroaarcoma.  It  lu'conifs  larj;t'i_\ 
an  iixlividiial  matter  with  tlio  ohsorvcr  as  to  wlini  a  k'vcii  tumor  will  l)«' 
(■ailt*<l  fibroma  and  when  it  will  he  ealletl  fihnisareoma :  the  tiliroma  itself 
shows  far  more  nnmeroiis  ceils  than  does  ordinary  fihroid  tissue.  It  is 
often  difficult  to  say  when  the  cells  l)ecome  so  inmuTous  in  a  jjiven 
area  as  to  justify  the  expectation  that  a  tumor  will  lieeome  infiltrative 
and  metastatic. 

Myxosarcoma.— This  name  is  );iven  to  tumors  in  which  the  myxom- 
atous cells  with  their  characteristic  prinrsses  are  a  feature,  l)Ut  in  which 
also  there  are  islands  of  closely  |)acked  round  cells  without  processes, 
which  are  evidently  less  ditferentiated  and  more  rapidly  >;rowinj;. 

Liposarcoma.  .\n  ol>vions  lipcmia  ^rowin^  slowly  for  a  loii^  time  may 
take  on  rapHJ  jjrowth  and  show  sarcomatous  areas  where  the  fat  cells 
are  replaced  liy  a  tissue  that  is  richly  cellular.  Such  a  tumor  may,  nf 
course,  ni\«'  sJircomatoiis  metastases. 

Chondrosarcoma.  In  a  rapidly  ^rowiii^  chondroma  there  is  some- 
times found  a  rapid  transition  from  unmistakahle  cartilajte  to  richly 
cellular  tissue  that  is  evidently  sarcoinatotis;  this  is  a  gradual  transi- 
tion from  highly  ditferentiated  cells  to  tiiose  less  ditferentiated,  the 
reverse  of  what  occurs  in  tlie  normal  j;rowth  of  cartilage.  As  the  vas- 
cular sarcoma  tissue  becomes  formed  it  can  he  seen  to  advance  into 
and  replace  the  more  typical  cartilage,  so  that  we  have  the  j)ictiire  of 
cartilage  formation  and,  superimposed  upon  the  neoplastic  cartilage,  a 
sarcomatous  modification. 

Osteoid  Sarcoma,  Osteochondrosarcoma,  and  Osteosarcoma.-  Tluse 
three  terms  indicate  ditJerent  types  of  sarcoma  exhil)iting  varying 
grades  of  the  process  of  ossification. 

The  osteoid  sarcoma  is  malignant,  grows  rapidly,  and  forms  metas- 
tases; in  it  are  areas  intermediate  between  cartilage  aixi  b(>ne,  that  is, 
there  is  a  homogeneous  matrix  in  which  the  cells  are  more  like  bone 
corpuscles  than  cartilage  cells;  sometimes  there  are  several  in  one 
space.  These  cells  are  seen  to  surround  thickly  the  osteoid  lamella  or 
mass;  they  are  polymori)lious,  and  sometimes  giant  cells  (M-ciir;  in 
studying  such  a  tumor  one  is  convinced  that  the  osteoid  tissue  is  part 
of  the  tumor,  and  that  the  tumor  cells  have  laid  down  the  imperlVct 
bone. 

The  osteochondrosarcoma  is  more  perfectly  ditferentiated,  and  tlitre 
may  be  a  deposit  of  calcareous  salts  in  the  lamellie,  while  yet  other 
cases  show  both  true  cartilage  and  true  bone. 

The  osteosarcoma  proper  shows  lamellie  and  masses  that  consist 
clicmi(;ally  of  true  bone.  Flistologically  it  is  imperfect,  the  bone  Ik  ing 
in  isolated  spicules  or  in  thin,  spong\  irregular  masses.  Or,  juiiii, 
especially  where  the  periosteum  is  concerned,  radiating  osteopli-tes 
ajri-ear.  This  is  true  bone,  although  in  a  tumur,  just  as  there  nK\  f>e 
true  muscle  cells  in  a  myoma. 


■-X 


■iPP 


:..rV;^ 


^^Pf 


I'AriLW.y.i 


25: 


llHTr  ,.r  su,m  i.utlu.nties  who  are  .inwillinR  to  lulmk  that  true 
-.,..  .;,„  t  u.s  rxrst  „s  a  p„rt  of  a  t..m„r,  l,„t  the  fact  is  ac-t..allv  so. 
01  ..  urse,  tlu.  mor,.  p^rfc-rtlv  an.l  fonsi.hTal.ly  this  l,„„y  si.hstan'c..  is 
i^H.  .low,,,  the  less  mal,K„ant  is  the  tumor.  a„.i  we  ac-tuallv  fi,„| 
'"  ".'- "•"*'f  ,"^  W^^tl's  wuleiy  .hfTereut  powers  of  .„aliK„a„..v.  just  as 
-  Cm. I  wulelv  ,1,  erout  h,stolo«ic„l  pictures.  The  sa,..onm"eleme.,ts 
'"■'.;  I-  -!..".  I.Ydls.  pol.vKoua  ,ells  of  various  si.es.  ^iant  cells  (espe- 
rK,ll>  .-.  ceutral  Krowths).  an.l  over  the  growth  there  is  Keuerallv  a 
|.ri.,>teal  forn.at,,.,,  of  l.oue  which  is  thi„  au.l  rea.lily  l.roken,  ghiuK 
r^r  ...  the  fanuhar  •cKK-shcll  crackli,,,.."  As  a  rule,  they  .|o  not  form 
III.  t;i>t;,M's  iiutii  the  superfical  periosteiun  is  hrokeu  through 

Rhabdomyosarcoma     This  form  appears  in  the  ki.lnev  and  els.-wl,ere. 
.■;p.,,Mi  .   as  part  of  the  pluripotcntial  tumors  that  have  Let.,,  meni 
ti'-i..  .     J  hey  niay  show  unperfect  nmscle  fibres,  transverseh-  striate,! 
i'ln-li.'  cells  with  lo„«,t„du,al  fibrillation,  or  large  polvmorph'ous.  o  te 
"H  tmu,.|,.a  e  cells  of  sarc-oblastic  type.  althouKh  it  is  not'  noceksari^J 
>.itc  t..  say  that  all  such  tumors  arise  from  sarcoblastic  ceIN  onlv 

GUosarcoma.--\\e  have  referrt.l  t,.  these  tumors  in  connection  with 
I-  n.  „,a,  an,l  ,t  w,  I  be  recalle.l  that  the  .letermination  of  such,  as 
,  Mm.t  fn,„.  a  s.n.ple  roun,l-c-ellcHl  sarcoma,  often  .lepen.is  upon  the 
rit.  Ill I..I,  ,.f  a  few  unperfect  glial  fibrils  and  cells. 

PRIMARY  LINING  MEMBRANE  OR  LEPIDIC  TUMORS  (LEPIDOMAS) 

it  ..iiist  b..  u.idcrstoo,!  at  the  outset  that  while  these  tumors  show 

jl-.i.l.||iat,.M,  ot  tissues  yet  the  essential  part  of  them  is  the  epithe- 

I   'T  ,'la,Hlular,  that  ,s,  the  hning-membrane  element.     It  is  essen- 

'   to  have  a  stroma,  and  the  very  ,,resci,ce  of  the  lining-membrane 

'-'-nts  render    the  stroma  more  ,,roliferative.  but  this  growth  is  not 

--ir,l^  „,ore  than  .rritative,  that  is.  it  is  not  truly  blastomltou 


TYPICAL  LEPIDIC  GROWTHS 


Papilloma.     'lUv  term  papilloma  conveys  to  the  min.l  nothing  but 
'  """f '  •J«:-^^T;pt.on  of  the  form  of  the  tumor,  and  makts    m 

^'  i;:i  tti'*^  ';"'"'"T'i  '"^"^*^'  ^-^^  ^^-^  ''■•■  ^-'-^  «^  ^--"o 

I"  r..t<  re  to  utilize    h,s  term,  couple,!  with  a  qualifving  adjective 
'  li-t"  the  nature  of  the  papilloma  under  discussion.    PapUlomas  are 

'It   :.'''].  Z;"'"'''  T''^  '•^'  ^^"*'^^'"'"^'  «'-^'-^  famous  or 
'••  '■'''"« '^.  ^on»ect.ve-tissue  core  to  each  in.lividua^  process 

lt^Pc^.       U.7      T  "'^  outgrowths  of  the  corium  covered  bv  a  thick 
.1'-^  ■vine,!  epulerm;   they  arise   apparently    from    irritation,   are 


'WllfiLi^iii&/a^ii:^ 


258 


I'RoaUHSSlX  K   TlSSfH  (  ff\\an>! 


«oiiiiii()ii  ill  cliilillicxMl  aii<l  vniitli,  iiikI  tnul  to  disippt-ar.  Some  con- 
sular till  n  infect ivf.  anil  there  is  cDiisiih-rahle  c\i(leiite  in  favor  nS 
their  Itciiij,  traiisiiii»il)le  (Fij;.  Idt). 


Kill   im 


Thr  viirioUH  ^r.:(li'»  of  warls  »iiil  culaniiiii!!  iiaiHllniiiiix       (I'lrls") 

(//)  MoUnsctun  Contaglosum.  Tiiis  is  a  definitely  eoiitaj;i<»us  slim  ih'>- 
ease  arising  as  small  red  masses,  hecominj;  warty,  underfri.ing  central 
necrosis,  and  discharKiiiK  <heesy  matter.  The  cpiderm  is  not  greatly 
overgrown,  and  there  is  as  yet  no  definite  evidence  as  to  a  parasitic 
origin;  some  interest  attaches  to  the  condition  l)ecauHe  in  it  have  hteii 
(lescril)cd  intraeellular  bodies,  like  the  so-called  cancer  bodies,  which  at 
present  are  counted  to  fic  of  degenerative  origin. 

(c)  The  Condyloma.— ("ondylomas  are  warty,  nodular,  or  cauliflowiT- 
like  growths,  occurring  as  a  multiple  development  on  the  external  geni- 
talia, in  the  anal  region,  or  in  tin  mouth.  They  occur  as  a  seqiu  I  to 
uncleaniiness  in  the  presence  of  venereal  infection.  It  is  proliiMy 
safe  to  say  that  syphilitic  infection  is  always  present,  althougii  tiie 
condyloma  niust  not  lie  confounded  with  the  so-called  simple  venereal 
wart.  The  condyloma  shows  an  outer  wall  of  thickened  overgr  wii 
epithelium  lying  iipon  hypertrophied  connective  tissue,  which  i^  the 
?cat  of  inflamnifttory  infiltration;  essentially  benign  in  itself,  the  .  r.n- 
dyloma  may  become  the  seat  of  a  true  blastomatous  growth. 


I'M' ILIA  KM. 


259 


■   Hro   >triuiKt'-lf>(.kiiij, 
ii-iH-t  from  till  Mulp 


ul)  CuUneoiu    Homa  ( ll;,i>rdrratmis).     '11,. 
pr..,,>M'>  of  homy  coriMitiitir.ii  w|,i,|,  proj.rt 

rii.l  till-  filer;  tlii-y  are  liioviihlf.  the  l.iiMf 
iMiii);  soft,    'n,,'  horti    is  ail  o\tT<l«-v«'lo|»- 
riKiil  of   the    kcnitiiioiis    iiiatt-rial    in    the 
^kin,  iiloiiu  with  a  laihire  of  the  same  to 
Ih    rMm\   off,  so  that   an   ucriumihition 
«"  urs.     More  than  this,  howTvrr,  the  (rlls 
tlin.iinhoiit    ih»'  •■iitiro  i-pichvinis  may  ht- 
«"riic  keratinize.!,  while  tie  vasenlar' core 
"t    tin    pajilla   or    horn    i>    j,reserve<|;    it 
MTiii       'erefori,  a.-,  if  \\r  |,a,|  to  do  with 
.1  <l<-ir.ii«Tation   rather   than   a  trne  hhis- 
tniiia.  or  e\ei.  a   [.iirely   irritative  j)heno- 
tii.non.     (See  later  iiiujer  Degeneration.) 

'■<  t  Coccidlosls.     To  imiicate  how  paiiill,,- 

iii.itnii>j;rowths  may  arisefrom  irritation  we 
iMii>  Mote  the  oeeurrenee  of  papillomas  diu- 
I"  the  (-omdnim.  whieh  i>  one  of  the  sporo- 
zoii.  This  parasite  appears  to  he  alim)st  de- 
^""1  "I  n.arked  irritative  power,  and  vet,as 
H  n  -lilt  „l  Its  very  slif;ht  irritation,  there  is 
.M.-Mve  proliferati..n  of  <ells,  espeeiallv  of 
'"•  I  "tl.'l.al  type,  with  seareelyanvtendeiKV  to  necrosis      Ft     f      i 

"  '"■ ■'"'-  •"  '«■  >■""«  --■«.-  ,i,„„  .\;i,'™;,;;:2;;,i  ™o!"t,uI,:: 

Km.   100 


»"n.l.vloiiiula„f   Ihc  vulvu.      ((Jnti.) 


ih  a  bile  duct  becomes  pajMlIomatous,  and 


if 
projects 


2(i() 


i!3^ 


i'i{0(!i{h:ssivE  rissi'K  <'ha\(ies 


ill  (Inidrifyiiii;  inassrs;  at  first  Jiliiiic*'  siicli 


truly  new  jirowth.  I>iit  tin-  coiitimiiiiicr  and  the  fiirtl 


a  cmKlitioii  apfH-ars  to  Ik- 


\vr  irrowtli  of  the 


I)a])il!:itt'  niassfs  oc(  ur  only  with  tin-  contimu'd  pn'sciur  of  the  coccid 
and  nn'tastasis  lu'vcr  occurs. 
I/)  BilharsiasU. 


la, 


Th 


V  fir: 


%'^ 


Klu.  108 


•vt'ii  more  blastoinatons  in  character  than  the 
last  IS  this  condition,  in  \vhi<-ii  (Fi>;.  1(»7)  growths  in  the  rectum  and  the 
Madder  are  initiated  hy  the  ova  of  Hilharzia  hematohiuni. 
of  this  parasite  haviuj;  a  s|)ike, 
are  alile  to  tra\el  throuj;h  the 
tissues  and  in  the  Madder  and 
rectum  induce  hematuria  and 
melena.  In  hotli  these  or^'aiis 
we  find  papillomatous  i)rolifer- 
atioii  of  the  nuicosa  and  not 
iiifrecp:  Mitly  this  irritative  over- 
frrowth  jrives  place  to  definite 
carcinoma.  It  is  evident  that 
the  stimulus  to  growth  and  the 


ii)it  of 


frrowth  are  ac(niired  l)v 


the  ei)ithelium  durinjr  the  loiij;- 
contimied  presence  of  the  |)ara- 
site,  and  that  the  final  assump- 
tion of  carcinomatous  process  is 
the  expression  of  tliis  hahit  of 
jrrowth.  and  is  not  de|)endent 
upon  tile  continued  presence  of 
the  ejTK. 

lihiMfiiintitoiix       I'dpilli 


(ii)  Soft  Papillomas. 

growths  tiiere  are  main    forms 


IIIIHI.I. 

Of   tl 


U'se 


Tk;.    1(17 


HiUiarzia.si..4  nf  (hr  rcrtiim,  to  slutw  papillntn. i» 

,       ,  '  lii'iiialc.liiiirii,       i.vnvriiwtli  i>f  tin-  iimc(),Ha:     '!.  nivilii'n   tillid    uilh 

I"  sl,„»  ,.,!,. rr„i.mi,  h,   l„t,.r,,l  s|,ik...     iI'itIs.)       I,1,„„|.      (I,.m.,».) 


<>vu..f  H^n,:,r^.,•,(S.■l,i«t..,• 


f^oma  mere  n..dular  protnherance  of  the  mucous  membrane  to  a  mass 
of  delicate  long  fiiiKcr-like  processes;  the  nodular  process,  and  eii.li  of 
the  hnj;er-iike  growths  alike,  has  a  framework  or  stock  of  eoiinc(  live 
tissue,  III  whicii  run  the  vessels,  while  on  the  outside  the  coveriiiir  is  of 
the  einthelium  of  the  part,  often  with  ahimdant  mitoses  and  niten, 
too,  showinir  the  utmost  specialization,  as  when,  in  the  intestiiii',  it 
showri  abundant  goblet  cells;  on  the  other  hand,  it  may  be  modified  by 


PA  PILLOMA—A  DESOMA 


201 


■l"1.l«;crH„f  tin.  v.,i,,,l  li„i,',g.  '  '''"  """  """"•■'".>■  f»"i"l  ii.  Ih, 


may 
the 


I'm.   ll)!» 


I'Ki.    I  Id 


^t=*^^.' 


"" ""';;""l-''l"^'-h"wtl,..|..n«,fi,.«„HH.e 

l>"|)in.iinat.,ii«  „iilKro»tlis.    (Hibhcrt.) 


Ono  of  „,e  fine  „„,„„„„  „f„ 
«l.- «    ll„.  ,.,.nlral   (il.r.M.s    ,,,p.    ..^   „,„.,k 

Willi   VfSwIs.  '* 

'-li'^K  to  fill  ,„,  the^avi^   .  '  r  .". ''"r  "/^ 

ti-"-.  ami  vessels  is  JcZar    i  Vhe     ni^l    i'?"  '"'■'  "^  ^-""m-etive 
'''••'■  i^  to  he  eo„si.lere,l        t'le  LT  ''^'*  '^  ''■''  •'V^TKroutl,;  this,  in 

;j'i;;"'i=^  activity  ap;:i;;i;;;  n;:tSt:^the?;r:':>/ ,::""'"-•  *"^ 
S:.?;;;;r-:s;?'!;;rs 

Adenoma.     An  adenon  -,       1       '  "'^'*'^''*'">''  »''•'  •■"clerlvin^  tissnes 
''"'•nNtly.  having  its^pitTeHmn  •  rr^^^^^^^^  .^'-V-'^^"""''  «^  "prosse, 

"'•  •  'I  "f  Klmulnlar  aeini  ^^^  '  2  " "^  .  : '  ^fl'^^^'*  ^''"*  tissne  he  eou,- 


tiiii  , 


'"  \vith  hi.nina-  if  -.s  n,  t  u  I  ,  thea.fenon.a  is  in  the  form 

'"■'•  of  a  .i.Kt.    There  is  thus  ,  u!  "'^'•"•'»"  t   :<es  on  the 

-.  >t  is  n,...essary  to  know  f'n.  .  w    ,t        .    ■•';""    •""  .f  •^"'•'"'  " 
^-.n  .  .....ever,  are  eo.„r l.rilfUk:  '^'  '^  "^'^""'"^-  ^'=--- 

^-.;4arith;^::ii;^^ 


262 


PROGRESSIVE  TISSUE  ClIAXGES 


goblet  cells  and  discharge  mucus;  of  the  thyroid,  some  form  c-olloid,  and 
of  the  liver  some  pro(Uice  l)iie;  and  as  sucii  growths  are  sometum's 
encapsulated  within  the  tissues,  and  are  iiicapahie  of  discharging  their 
secretion,  the  secretion  is  apt  to  accunnilatc,  distend  the  structure  or 
the  tubule,  and  form  cysts,  the  cyst-adenomas. 

In  studying  such  a  growth  as  tiic  adenoma  we  come  at  once  to  tin- 
difficulty  presented  by  such  a  fact  as  this,  that  two  tumors  of  the 
same  organ  mav  develop  histologically  similarly,  and  yet  one  wdl  form 
at  the  most  a  benign  cystic  growth,  and  the  other  a  solid  tumor 


Fio.  Ill 


1^r 


Odfc- 


■•Z,^' 

^#4* 


■^P. 


!-...,■  ;  v»'- 1/ 

•  •    vr  V    -    *    .■■•*. 


■'    ■.■■■■■  .  -ic'V-  •  ■  ■■  -^r-:^ ' -^"t^X-:.-  ..  ■ 


-r::. 


»^^:v; 


'.!    '/^.-^ 


•'lit''       '■^•V''-'  ■       ■ 


'•■t'„--^r- 1.'""- •••  -  .■  -  4  ■■■' •  «•'•    " 


A.k-nonm  ..f  liile  .lu<-t^.  f..rnii'.l  of  ar-ini  r,.s,-n.l.Uim  th..«-  of  nor.n.il  l)il.-  ilucts.    (WiU..>l.l  ) 

mass,  having  some  of  the  characteristics  of  the  carcinoma.  We  have, 
in  l:.ct,  to  recognize  that  in  the  adenoma  we  have  a  grade  of  overgrowth, 
('■ifTerent  only  in  degree  and  not  in  kind  from  the  inflammatory  or  irri- 
tative hyperplasia  of  epithelium  on  the  on<*  hand,  and  a  malignant 
glandular  carcinoma,  on  the  other.  As  we  have  done  before,  we  can 
divide  the  overgrowths  of  glan.lular  tissue  into  (1)  irritative  mii< 
(congenital  glandular  hyperplasia,  (2)  adenoma  (encapsulated),  and  (.ij 
adenomatosis  (non-encapsuiatetl). 

We  Iuim;  said  that  two  adenomas  may  grow  from  the  same  onran, 
one  being  cvstic,  the  other  not;  ioic  being  capsulated  outside  ot  me 
mother-tissue,  another  being  -apsiilatcd  within  tlietissue;  oneniay  lia\e 

ducts  that  oi)en  and  dlow  secretion  to  be  discharged,  while  th cr 

is  closed  ui)  and  mav  become  cystic.  Because  some  of  these  adenciuMs, 
like  normal  glands,  connect  with  the  ducts  of  tlie  organ,  it  bc-nies 
very  difficult  to  separate  them  from  inflaininat('ry  hyiH;rtrophies  -i  tiie 
or-an     For  example,  a  difiusc  Hi>roi(i  induration  of  the  mammar.v  _  ma 


mmm'mmsmmmm 


ADlCXO.\fA 


263 


>l...un  in  succession  bv  the  Im  ,       .        r«. *"^'''  '"'"^^  ^"^"  '^e 

cccs  of  degree  and  not  of  kind  "'  *''''  ^''^'"^''"'^^  '^'^'"^  J"^^^- 

t.:/!;de;i:f:^^:'^,,^';!2,s't';r  t'r'^""^  ^'-^  '^^ -  -^ 

wlnehlmve  never  attaillfulldl  r""''  "'"'  '*  '•^'"'^  ('"  ^'^'"-^'^sts) 
take  on  independent  a  hh^f't  "",'"•  '"'^^' """'"  ^''"P'^  ^timnli 
-lone  bv  full vdifferenti  Id    it^.^^^^^  characters,  the  same  can  be 

Histologically,  the  stroma  is  an  imDortint  ,v.rf  ^#  .u       i 

E';h:xrESi£F^^^^ 

tla.  lormer'is  the  nufre  iml^^^^^^^^^^^^  ""'i  "P«"  ^^e  ether, 

t'"'l"«s  that  of  the  ephhd  mn       ,;/      t    '      f  ^'^^'^'^  "*  *''^'  ^^''^'na 
""-"Hs  in  mice  it  is  the  tra  in     .   /l  ''T'f'T'"'''  ^^  ad^""'H'arci- 

^'"'  >troma  being  fuJnL'S  ^f    ^  .^^ll^^  '\\ ^^f  "V'^V""^ 
^•coiidarv  to  the  irrowth  -♦•      •'    ,■        .  ^'"'  ffrowth  of  stroma 

"'••  '-".u-ctivc-ti  sue     ™  '••-""^tion.  then 

''•■^•'"pi'iKiicoulasm     Tl ,    n  '    '""*  ""   *''*^  nutrition  of  the 

'''••'-H..p.op:^;rs'tt.!^;n:r'^;Nn^^^ 


uit 


Ml:l 
en! 


t'\. 


'  "<-•  .liffcrent  degree,  of  overgrowth 

Congemtal  Glandular  Hypertrophy  \,,   ,.v.,m,.i.      t  .i-  . 

-  ^-rovvth  of  the  nnnnZnZul  w  i<  ,  Vn  "   't' 

"■y  development  of  niih,.rt\..  V      ■        •    '' ""^^   "P""  the 

'-"-vn  t,.^;il    n^f'  ,  y;"^-''  *«''»'"  "lar  overgrowths  have 

■'n.>rnnd  mirmarv  gland     *"  '"•""•   '-^"'»*'--"y.  to  l>.    „„ 
''ian.i.\   to  hbrobis,  as  occur    frequentl.v   in  th^  breast. 


204 


PROGRESSIVE  TISSUE  riiA\(iES 


Glandular  overgrowtli,  thoiiKli  to  a  moderate  extent,  does  apparently 
here  exist.  A  similar  condition  is  tiie  overRrowtli  of  the  mucous 
memhrane  of  the  di^estiv.-  tract  at  the  ed^'e  of  an  ulcer;  prostatic 
hyi)ertrop!iy  prohahly  helonjjs  to  the  same  category. 

.'5.  Adenomatosis.— This  is  the  condition,  closelv'  related  to  the  last 
nientioned,  m  which  i)ortions  of  a  gland  or  a  surface  become  the  seat 
of  adenoma,  the  overgrowth  occurring,  not  from  a  aiuyW  focus,  hut 
sunultaneously  from  many  foci  at  the  same  time.  Kxami)Ies  of  this 
lorin  are  the  multij)le  jwlypoid  adenomas  of  the  alimentary  tract,  or 
nnilt.pic  adenomas  of  the  liver. 

4.  Adenoma  Prop«r.  'J'hese  are  the  demarcated,  encapsulated,  benign 
overgrowths  of  glands.  They  are  not  numerous  compared  with  the 
examples  of  adenomatosis,  and  they  ai)pear  to  originate  from  cell-rests 
Wiier  the  cell-rest  is  formed  of  gland  tissue  normally  comnmnicating 
with  the  exterior.  comj)lete  eiicai)siilatioii  results  in  cvstic  formation 
and  the  cyst  may  become  the  seat  of  intracystic  pai)illomatous  growth.' 
An  absence  of  secretion  indicates  either  origin  from  non-secreting  cells 
or  a  highly  marked  grade  of  anaplasia.  Here  also  lielong  the  encapsu- 
lated cystic  adenomas  of  the  mammary  gland,  as  well  as  the  large  group 
ot  .idenomas  which  arise  from  the  remains  of  th,-  Wolffian  duct,  although 

f^''."    '  adrenal  a.lenomas  are  related  very  cioseiv  to  the  transitional 

lepidomas. 

THE  ATYPICAL  LEPIDIC  3ROWTHS     CARCINOMA 

I  p  to  the  middle  of  the  nineteenth  century,  an\  malignant  growth 
was  desigiiate.1  a  cancer.  With  the  developni  tit  of  morbid  histologv, 
pathologists  came  to  use  the  term  cancer  as  svnonvmous  with  car- 
cinoma and  as  sharply  contnisted  with  san-onia."  Within  the  last  few 
.years,  with  the  development  of  "cancer  research,"  and  with  workers 
ill  this  dej)artiiieiii  studying  both  carcinomas  and  sarc.mas,  we  are 
reverting  to  the  oUlvr  use  of  the  t.Tin.  We  shall  thus  emjilov  the  term 
cancer  iMdiscrinuiuit<'ly  tn  iialicat.'  a  malignant  growth  of  anv  order, 
tlie  term  caniiioina  to  denote  niily  cancers  of  eiiitheliai  and  glandular 
origin. 

Carcinoma.  We  here  consider  atypical  growths  of  both  covering 
e|)itlielnim  and  of  ghuid  tissue,  and  point  out  fhat  the  properties  of 
both  are  alike,  to  such  an  extent  that  the  most  atypical  form.-,  are 
scarcely  distinguishable.  Here  if  anyxvhere  are  found  excepti(.n->  u> 
the  ruh-  that  the  greater  the  .Jcgree  uf  anaplasia,  of  depi  rturc  from  tiie 
adult  normal  histological  type,  the  -reater  is  the  malignancv,  for  M.ine 
of  these  carcinomas  in  the  primary  growth  defiart  but  little  and  .ire 
exceedingly  iiiahgnaiit,  while  some  that  are  greatly  anaplastic  ar.'  <>! 
relatively  mild  malignancy.  A  good  e\anii)le  of  the  latter  is  rodent 
ulcer  (called  basal-ceUed  carcinoma),  a  v<Ty  anaplastic  kind  of  gro\  th 
which  for  months  or  \  cars  shows  a  local  malignancy,  but  which  in  in.ny 
cases  fails  to  form  metastases.    Of  those  api)arentiv  slightly  anapla  lic. 


■?-■?■':  »"»r'^-%  ■Hi' 


CARClNOAfA 


2r)5 


\<t  MTV  tnali>iiant,  as  cxcninlifipfi  K,. 

-  N.M„i„atio„  will  show  s  S"  Cnrt    e^^^^       «<  enocarci„omas.  caref,,! 

■''-."<-  ••'•  "  ''.•'snnent  Mul.rau      ,%;.''"  ^''^ ""••'"«''  «"«el.  as  tlu- 

■""drdh,  aUiinral  ,r!h.  '  "'"'  '*'•"'  "'"■^'"■>-  "f  ''<lh,htly  „U,l>iml  „r 

Relations  of  Tumor  Cells  and  Stroma  -  \  «  ; ,,  ♦  i       i 

niMtinn  IS  cften  u-rv  well  niark^.!    /..'""' •'•""^■«''"'-    -Stich 

-".  ^.ppoanuK..  with  a  -aiWen.:;;;;^;;;;;^,:;^ ( j,^^^;;;^'^^;:;  w 


tin. 
^uhI,-, 

tll,.; 

ilMlic, 

prir\ 

i'n.li:, 


;t..;;m.l7fc;t^'-|--!l^.-tnuethe,. 

I'l""'-;<s  -ndusions  in  the  tu.nor«  11^        n      • '  '"■'  "^''"  *»'^^"  "P 

:"""^  that  the.  activeh    J       hf'      ^  '.''-^"rKan.zatmn.    There  are 

'  ""^'  tissues,  a,.,ra,  nre,  '^  <arcn,„,na  cells  fee.l  „,„„,  ,  J 

'  •  -•'   '•>•  Pr.1  .n"     Chiton'  r"- ■*'""•  ''^^  -^^--l'"l«r 

"'  ^'"'  fi-^^ne  is  „se.l  t.,  f„  ,     f. u'.  s  !    '  ""/''.*"  '''^'''  ''=""'•  t'-e 

.'"'  ^'- '-""-  ...av  sti,  "t,  s„,h  T;'  "*  "'■  """•"••  «"•'  ♦'•-' 


-'^^•nr 


uui 


2fif) 


PROGRESSIVE  TISSCE  CUASGES 


order  of  ti?<sue,  as  is  seen  in  the  prtMliiftion  of  new  bone  in  a  seeondary 
carcinoma  situated  in  a  hone;  or  yet  furtiuT,  the  stroma  may  l>e  excited 
to  an  atypical  overjjrowth  itself,  giving  rise  to  what  is  a  true  carcinoma 
sarcomatodes. 

According  to  the  degree  of  reaction  we  are  accustomed  to  use  certain 
descriptive  words  to  denote  carcinomas  of  different  consistence:  (1) 
medullary,  where  the  cell  growth  is  abundant,  and  the  stroma  incon- 
siderable, the  resulting  tumor  being  cellular,  soft,  and  like  marrow 
(medulla);  (2)  scirrhous,  in  which  the  stroma  is  abundant,  the  tumor 
cells  being  scanty  and  compressed;  and  (li)  carcinoma  simplex,  where 
no  marked  predominance  of  one  over  the  other  is  noticeable. 


:r.-f.:^*|^yv^^| 


Kpithcliimm  of  lip:     a,  n,  epitbi'liul  "pt'orl':"  '>•  Bmall-rclled  infiltration  of  Burrounding 
tissiu'  at  iwriphrry  of  nrw  growth. 


K 


At  the  edge  of  a  carcinoma  the  cells  generally  stain  deeply  and  are 
intensely  vegetative,  and  while  less  so  centrally,  there  may  yet  in  this 
position  l)e  mitotic  figures,  indicating  that  the  growth  is  not  only 
peripheral.  Generally,  degeneration  progresses  fairly  rapidly  in  the 
deeper  parts,  and  this  degeneration  sometimes  varies  according  to  the 
function  of  the  tissue  from  which  the  tumor  is  derived ;  thus  fatty  changes 
are  common  in  mammary  gland  tumors  (recalling  the  active  part 
taken  by  the  cells  of  that  gland  in  supplying  absorbed  fats  to  the  milk), 
and  mucoid  changes  in  tumors  of  the  alimentary  canal  (in  evident  rela- 
tionship to  the  normal  function  of  the  goblet  cells  of  the  nuuinis 
membrane). 

"Cancer  Bodies." — These  are  bodies,  found  in  and  between  circi- 
nomatous  cells,  which  have  often  been  supposed  to  be  parasites,  ami 
the  cause  of  tumor  growth,  but  which  are  at  present  considtTnl  to 
be  cellular  degenerations.  Thus  we  encounter  small,  hyaline,  s|)li'  -^ical 
bodies  of  varying  size,  the  mean  size  being  that  of  a  red  corpuscle  \  hich 
stain  intensely  red  with  fuchsin,  and  lie  singly  or  in  little  groups  attuhed 


PLATK  VI 


'\I\'mIi    Ii  ,,in    E<l()e   I  .(    ii    Ci 

^'"'"•'1      ''^      Si|,|:,,i       III      ;in.l      h, 
■"       ""lIllnMll,!       |,1,,|„.,I\       ,,ti      Hit- 

'"    "i'ni.iiv      ,|l:,,,.|     (^ 


ir<  Jiioinfi   .,(■  thf    Miuninnry  Glnnd. 


p.-iil     .,1      ,i,ii.-,-r 


■  v.\     11,.-    r.-l»-iil 


I'ln    ol    idi- 


l:ill\        ,||,,| 


|>"'   im.-M    ,,l     Pr.,1,. — ,,,     Kl 


•IK     ,|, 


rive-rl      In. Ill      tl 


M"l -:      '..     11,1. .Ill 


■I/'.        ,1,    .■,.||-.     cli^l..,nl,-.|      Willi 


.l.-\..i.l      ..I      II, 


-111  ■      '.     i"iniiiii~     ..1 


y . 


^^ 


'-iy^its?-. 


CARCINOMA 


267 


to  Olio  iinotlier,  hotli  intracellular  and  free  in  the  struma.  They  are  known 
us  "Russel's  bodies,"  after  their  disatverer,  ure  met  with  not  only  in  mHlig- 
iiaiit  growths,  hut  iilso  in  inflaniniHtory  areas,  and  are  consideretl  to  he 
('\iinii)les  of  hyaline  dej{eneratii)ii,  hut  >.  hither  of  re<l  corpuscles,  of  cells, 
orof  ulhuminous  matter  is  still  unsettled.  Other  intracellular  bodies  are 
of  various  forms.  There  may  l)e  a  sinj^le,  round,  homogeneous  mass 
l)iishiiii{  the  nucleus  aside;  <.r  such  u  ImkIv  with  a  metachromatic  central 
part,  or  surrounded  by  a  clear  space  or  a  perij  herul  ring  staining 
ilitl'erently  from  the  rest  of  tht;  body,  or  a  peripheral  ring  with  processes 
coiiiueting  it  witli  the  cytoplasm,  or,  again,  a  central  b(Mly  may  be  sur- 
roun<le<l  by  a  ring  of  smaller  globules;  or  through  the  cytoplasm  may 
he  scattered  abundant  small  bodies  lying  in  apparent  vacuoles;  or  even 
large,  amoeboid,  gregarine-lik«;  forms  are  seen,  sometimes  in  the  cell 
and  sometiTnes  outside  it.  With  so  many  forms,  and  such  failure  to 
correlate  rtsiilts  on  the  part  of  many  observers,  one  may  be  forgiven 
for  some  scepticism  as  to  these  bodies  being  caustitive.    Although  the 


Fio.   114 


hut.  115 


®     ^     i 
A 


^^■¥.-'-v 


Inirnrolliilar  bodu-dcf  the  type  of  Hun- 

'  1'^  fiK-lii^iu  txHlies  from  a  ea.H<^  (»f  cun- 
■  rmis  It'uknplukia,  in  ceUs  of  tUe  pltulina- 
'II  l5|H\     (Krompecher.) 


Cell  inclu^iona  in  cancer  cells— the  aupponcd  pars- 
nitcH.  It  will  U-  seen  that  the  btidiea  are  to  the  inner 
8i<le  of  the  cell  toward  the  lumen;  in  the  position, 
t  hat  Ih,  of  modified  iiecrctor>'  products.    (Greenough.) 


ilcs(rij)tioiis  recall  ihe  successive  stages  of  a  protozoan,  with  progressive 
tiil.irsjement  and  final  setting  free  of  spores,  yet  the  study  of  the 
tiiii  rochemical  reactions  of  mucin,  hyaline,  amyloid,  keratin,  and  other 
iliKciieratioii  products  shows  that  the  same  reactions  are  obtaineti  in 
ilif  case  of  these  bodies.  It  is,  t>f  course,  possible  that  some  one  or  more 
of  these  bodies  may  eventually  prove  to  be  [)rotozoan,  but  in  the  present 
-t  itc  of  <nir  knowledge,  there  is  no  sufficient  ground  for  supposing  that 
III  tliciii  we  liave  discovered  the  cause  of  malignant  growths. 

Site  of  Origin. — It  is  often  impossible  to  determine  the  first  site  of 

a  iiialigiiant  growth,  because  by  the  time  of  operation  or  death  it  has 

'iccoiiie  too  extensive;  but  in  the  case  of  .superficial  growths  it  can  often 

■cdttermined  that  the  origin  is  from  a  single  point;  yet  even  this  does 

•  t  iiitan  that  the  tumor  is  necessarily  the  progeny  of  a  single  cell. 

!i>  serial  sections  it  has  been  possible  lo  see  that  although  in  a  single 

'  tiun  tlie  alveoli  of  tumor  cells  apj)ear  separate,  yet  in  different 

iiic-  they  are  i.I!  connected  in  a  series,  or  a  Si't  of  series,  I'or  it  may  be 

-mI.Ic  to  determine  that  there  are  more  centres  than  one  of  origin, 


^^:^-. 


'\'P^-^.iS^ 


^^. 


V*<^  «■  ■:' 


mi 


^mtmmmm. 


h^ 

^h- 

i-4*  -  d%. 

m 

1  "v^ 

*** 

"'    ''''■  '  '  "iSi  ' 

v^H' 

.*■      ^1!*  -^^ 

I 

m 

W^ 

26.S 


I'RocRFs^nK  r/.-sTf;  rii.wofis 


thut  the  urowtli  is  iiliiria-iitric  arising  fruiii  st-vcral  <clls  in  the  snnip 
ri%'ii>ii  siiiiiiltaiu'(iiisl\ . 

(kca-iiiiiully  si-M-ral  primary  urowtlis,  widtly  M-paratfd.  aro  ni- 
couiittT'-d,  as  tM-nirs  in  tli*-  niiilliple  sn)MTK<'ial  );ro\vtlis  of  chiiinicv- 
-ivveoif  or  of  workers  in  paraHin.  and  U'st  (»l  all,  in  tlio  frwinency  with 
whicli  iKith  nvaries  arc  aM'trtcd  l>y  larfinoniii  lairly  frwiuently, 
t<K),  an  ihdi\  idnal  may  i-.\liil»it  two  or  more  distiiu  t  forms  of  primary 
urowtli  in  diHVrcnt  part  ot  thi-  ImmIv,  altliou^li  hotli  of  tlusi-  may  not 
he  malignant,  as  for  example  w  hrre  uteri  no  hhromas  or  thyroid  aiK'nomas 
coexist  with  ean  iiiomatons  frrnvvth  elsewhere.     It  is  not  iM)ssil)le  to 


.y- 


'■^t^  /■ 


::» 


M 


/A^.'i'; 


si-sa 


.^ 


V?  ii 


'y^t) 


W 


Karly  rpitlii'li'itii!!  of  |i.ni!iii'.  ti>  «liiiw  ('i)   ri'llimi  <>l  "riniii  hy  ili>»  l>-ltrii»tli  from  prrtxistillK  ipillic 
liilln;  '■,  h.  i'pillH'li:il  i«>arls;  r,  Kiiiiill-t'illi'it  iiitillratioii  ill  mirrouiiiiiiiK  ti.wii".     (IVlenh'n.) 

iio  farther  than  to  state  that  the  same  instahility  of  tissue  that  iM-nnits 
the  overgrowth  of  tissue  in  one  plaee  in  a  typieal  (henign)  way,  afi'ectiiip 
numerous  tissues,  allows  atypical  overgrowth  in  another,  or  even  sub- 
sequently in  the  same  plaee;  that  is,  the  nudtiple  growths  arise  as  a 
sequence  of  a  vii<>  of  development  or  from  the  developn)ent  of  multiple 
cell  rests.  The  develoimient  of  now  si.i;,'l('  now  multiple  tumor-  is 
paralleled  hy  the  state  of  afi'airs  we  find  it  infection.  There,  generally, 
we  fin<l  a  single  tm-us  of  origin,  ah  li(i\ii,'ii  in  some  ?ases  there  appear 
to  1)6  multiple  simultaneous  dt  -.  I'lopments;  the  single  f''  is  (remaiiHig 
single)  is  explained   vipon  the  presumption  that  the  resistance  of  the 


%Jt 


(AliclXn.M.X 


2()9 


""l>   N  ra.M.,|.  .....i  furthor  .nvHsi,,,,  „t  nt\wr  ,M,i„ts  is  n-sisUNl      I„  „ 

"  pnv,.,.,  f„r  luT  .l..v,.|op,nn,t  ..Im-wIut...  .Uhou^U  nut  strl^Zl 
...  ..vfn„„,..  t  u.  t.nnur  Kr-wtl,  alrc-a.l,   i,.stitnt,.|.     That    his    2 
:m.  .■  .s  r....,l  ,s  sh„w„   ,y  th.-  fa.t  that  a  mum.s,.  i„.K-nhm..   w  th  r-  rri. . ,  m 

:i.:"i;:;;;;;;:;;;r;;;-:.::;'t;^''''''-'^^ 

Sq.ianioua-ceUe(l  Carcinom.  (EpitheUom.).  Tumors  uf  this  onler  ..rid 
.-..;  Iron.  s,,„a,nn„s  .•pithdin..,.  a„.|  an-,  as  sn<-h.  ehit.r,,  ?•  i  ,  .  f. 
on..n;  h„,  snu.  hvpoMastic  linin,  „„.„.l,rane  .nay  h.  ^^„ ^  ^  t 

Mnh.,..sopha,..s.tlnsals.Mnayuiverisc.tos,pun„o„sHdo^i<^^^^^^^ 
.i  -  th.  sk,n  Kh.n.|s  of  ..pihh.sti<.  oriKin  can  «ivo  riso  t    X,     ^    I 
.-..-.s  It  .s  c.v„|,.„t  that  MO  ahsoh.to  .listi.utior.  nn,  ho  ma.l    i  ,  t  J 
«.,v  ..  .•onsuh.r.nK  one  o  cpihlastir  an.l  the  othor  of  hvpol.K  •  or  Jin 
.  . .  unhMK  to  ,ts  roh.t,onships  an.l  its  functions,  a  jrivo,,Ii  „-,«,,„  3 ' 

1^  '|".^t,pc  oi  tlu.  ...other  t.ss„e  ,s  the  ,n«h«na„t  growth  that  arisei 

Fill     117 


III 

lull 

<l| 

iFi 

(Vli 

I 


is.r 

til. 


•lu'  >.|Ua.„ous^.eIh;.l  eareino.na  ,,resents  soli.l  eohin.ns  of  cells  ,,-,ss 

•-'.e  tint  tlu.   I-  "'     ?"'V'";  "^  *'-'^'  ""'"•'  ^•""  '-  "-"lerstoo<l 

'■'  the    m,  eeh  J'       "^i  T'l  """.^'"""•>-  «>'»^'^'>--     The  outen..ost 

projttte,!  part  would  be  those  of  the  .Malpighia.,  laver 


MtCROCOPY    RESOLUTION    TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No    2l 


1.0 


I.I 


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IIIM 

IIIM 

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1^ 

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1- 

1^ 

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2.0 

.8 


1.25 


1.4 


1.6 


^  APPLIED  INA^GE     Inc 

^P^  '•■''■'i    Lost    V'j'i    Street 

rJS  "Ocheslef.    New    'o-k         U609        uSA 

JjS  '16)    <,Q2  -  0  50G  -  Pt-one 

SSS  -le;    288  -  598^    -  Fa. 


mm 


270 


PROCRESSIVK  TISSUE  CHAXGES 


and  the  innermost  ones  the  normally  keratinized  cells  of  the  surface. 
If  the  imaginary  finger  were  now  withdrawn,  and  the  projection  later- 
ally compressed  to  ohlite  Ue  the  space  left  hy  the  finger,  the  solid 
column  so  resulting  would  show  precisely  what  is  seen  in  a  down-growing 
process  of  epithelium.  In  less  tyj)ical  growths,  the  difTerentiatioii 
between  the  cells  of  different  layers  is  hy  no  means  so  clear,  and  with 
greater  degrees  of  anaplasia  the  cells  may  he  round,  j)oIygonal,  or  even 
spindle-shaped,  as  may  happen  in  rodent  idcer  (Fig.  11!»),  and  in  this 
coimection  it  is  to  be  remembered  that  the  extreme  anaplasia  is  not 
necessarily  a  sign  of  extreme  malignancy.  These  tiunors  which  show  a 
failure  of  differentiation  toward  flattened  and  keratinized  cells  have  been 
called  the  basal-celled  carcinomas,  on  the  ground  that  such  arise  wholly 


Fkj.   lis 


ill 

Impurn  or  Iransitionnl  opithclionia  of  nntruni  of  Highmore  ("basal  ceiled  carcinoma"),  in  which 
instead  of  central  keratinization  and  pearl  formation,  there  is  central  rccrosis  and  autolysis  in), 
with  production  of  lunicn-like  space. 


from  the  basal  cells  of  the  I\Iali)ighian  layer,  although,  as  a  matter  of 
fact,  as  this  is  the  actively  growing  part  of  the  epithelium,  all  the  tumors 
arise  from  it;  it  is  the  degree  of  anaplasia,  the  incajjacity  to  develop 
beyond  a  certain  jioint  into  the  flattened  and  keratinized  cells  tluit 
determines  the  existence  of  such  tumors.  There  are  certain  difTereiiccs 
to  be  seen  in  the  squamous-celltd  carcinomas  according  to  the  site  of 
their  origin.  Skin  and  tongue  tumors  arc  apt  to  give  well-marked 
pearls;  oesophageal  tumors  are  not  so  apt  to  show  them,  just  as  normally 
in  the  a-soi)hagus  the  keratin  development  is  not  marked.  The  nitire 
rapid,  too,  the  growth,  the  more  atypical  it  is,  and  the  less  apt  are  tlie 
differentiations  to  appear,  just  as  the  process  of  keratuiization  on  the 
skin  requires  the  lapse  of  considerable  time,  and  a  constant  slow  pro- 
gression of  removal  from  the  dee])er.  better  nourished  layers  bel<>w; 


CARCINOMA 


271 


wlure  the  growth  i.  rapid  a.ul  the  cutting-off  of  the  cells  from  their 
n.itntion  correspondingly  hastened,  more  active  degenerations  (even 
ii.cTosis)  are  liable  to  occur  (Fig.  124).  Bcncruuons  ^e\en 


Fio.  119 


Fio.  120 


l''irlic,n  of  edge  (.f  a  rodent  ulcer. 


Part  of  the  same  at  a  more  hipihly  magnified,  to 
show  assumption  by  the  epitheUal  cells  of  aspindle- 
shaped  type.     (Krompecher.) 


S,,,umious-colled  carcinomas  are  found  occasional'  in  regions  which 
Mormal  y  possess  columnar  epithelium,  such  as  the  larvnx.  broi  chus 

...nach,  uteru.s.  an.l  gall-bladder.  It  is  in  these  verv  r;gions  hat 
"e  .Mc.unter.  either  as  the  result  of  metaplasia  or  otherwise,  islands 


Fia.  121 


Aberrant  s,,uamous  epithelioma  of  Rall-bladdcr.     (Von  Han«>nmn„.) 

''      tlKi"'tuZ!^T'  'f^^^^""'  '^"d  apparently  it  is  from  such  cells 

'         '  nit  I.  llorn    ou  T  "l     a7  "■'  ""'  ■"f'«'"«»t'.v  ™-ed-  showing 
:  ti<  ..oniatous  an.l  glandular  carcinomatous  constituents. 


172 


I'ROaiiKSSlVK   TISSCE  CllASdEti 


Gland-Celled  Carcinoma.— Tliesr  tumors  differ  somowhat  iucordiiif; 
to  the  structure  of  the  mother-tissue;  from  tuhuhir  Rhmds  we  are  ai)t 
to  obtain  tumors  that  show,  or  attempt  to  show  a  tul)uhir  arrangement; 
from  acinous  glands,  tumors  that  have  a  grape-like  arrang  ent;  from 
the  liver,  a  tumor  of  cells  arranged  in  solid  masses  runn"  g  in  irregu- 
lar strands.  As  before  stated,  it  is  necessar.v  to  consider  the  tissue 
from  which  it  arose,  before  one  can  say  how  typical  or  atypical  is  a 
certain  tumor.  In  the  tumors  which  show  a  distinctly  glandular  form, 
there  may  be  a  relatively  orderly  arrangement,  with  an  attempt  to 
form  lum'imi  or,  on  the  other  hand,  there  may  be  no  such  attempt, 
so  that  we  arrive  at  the  forms  in  vhich  the  gland  formation  is  lost  and 
solid  masses  of  cells  occur  with  more  or  less  abundant  stroma,  according 

Fia.   122 


,4^  I'f     •;••■■'•■  .•-aLM-*- 


m 


V^Tll 


Aclcnocariinoiiia  of  rrrtuin  (from  pnpiiralion  of  Proffsaor  Klotz):    n.  hoction  arrnss  tul)ular  ilinvn- 
growlli  with  largo  luimn;  6,  more  solid  iiiasn  of  aberrant  gland  cills  forming  multiple  luniina 

to  the  amount  of  which,  as  alrta<Iy  stated,  we  call  the  tumor  mechil- 
lary,  scirrhous,  or' simple.  To  nake  any  farther-reachiiig  classification 
of  the  gland  carcinomas  is  hardly  necessary;  at  most  it  may  !)_e  con- 
venient for  descriptive  puri)oses  to  define  a  tumor  by  an  adjective 
descriptive  of  the  form  of  its  cells,  as  columnar,  cubical,  etc.;  the  same 
carcinoma  may,  in  ditl'erent  sections,  show  pictures  so  diverse  that  one 
is  in  danger  of  laying  too  much  stress  upon  the  characters  that  ajMcar 
predominant  in  this  or  that  section. 

Degeneration.  -The  superficial  carcinomas  tend  to  ulcerate,  liy 
reason  of  the  ill-control  exercised  ui)oii  the  blood  sup])!.'-  and  the  exiiosiire 
to  trauma  or  infection  against  which  the\-  are  unable  to  protect  tlum- 
selves.  Extensive  mucoi<l  change,  "coUoid"  degeneration,  (Kciirs, 
especially  in  the  carcinomas  of  the  digestive  tract;  the  tumor  cellr.  -^tcm 


Fio    123 


Medullary  cancer.     (Kibbort.) 


Fia.  124 


■■rrl...s  nf  br,a.,t.     The  rella  are  compressed  und  degenerated  and  the  stro, 

X  250. 


stroma  relatively  abundant. 


Fio.  125 


IS 


Carcinoma  gimplcx.    (Ribbert.) 


274 


PROGRKSSIVE  TISSUE  CHANGES 


to  retain  the  power  of  protlucing  mucin,  hut  are  apparently  unahie  to 
proi)erly  excrete  it,  so  that  it  l)econies  heaped  up  in  the  cells,  distend- 
ing and  eventually  killing  them.  Whole  alveoli  may  suffer  from  this 
change,  so  that  careful  search  is  necessary  to  discover  cells  to  give  a 
clue  to  the  nature  of  the  tumor. 


Fio.  120 


If!. 

1: 


CoMoid  cancer.  Hhowing  large  alveoli  with  cell  rcmaiLi,  within  whir!    is  contained  llic  gelatinous 
culloid  material.      X  300.     (Rindfteisch  , 

Of  all  tumors,  cartinomas  or  malignant  epithelial  growths  are  the 
most  important,  both  to  the  pathologist  and  the  clinician.  Judging 
from  statistics  they  are  rapidly  increasing  in  their  frequency,  and  when 
not  recognized  early  are  so  hopelessly  fatal,  that  it  becomes  of  the 
highest  imiwrtaiice  to  recognize  them  at  the  earliest  possible  moment 
and  so  permit  of  their  removal  before  they  have  infiltrated  too  exten- 
sivelv. 


THB  TRANSITIONAL  LEPIDOMAS  (MESOTHEUOMAS 
AND  ENDOTHELIOMAS). 

It  will  be  recalled  that  our  classification  grouped  together  all  those 
lining  membrane  ti.ssucs  of  mesothelial  and  mesenchymatous  origin, 
derived  secondarily  from  the  mesoblast,  and  detei  mined  that  tumors 
arising  from  these  should  form  a  separate  class,  the  secondary  or 
transitional  lepidomas.  Of  these  there  are  four  groups:  (1)  tumors 
arising  from  the  developments  and  vestiges  of  the  Wolffian  and  Miillerian 
ducts;  (2)  those  arising  from  organs  which,  while  they  come  into  intimate 
relationship  with  these,  nevertheless  as  regards  their  essential  constitu- 
ents, are  of  separate  mesothelial  or  mesoblastic  origin  (ovaries,  testes, 
kidneys;  with  this  group  may  be  included  the  adrenals);  (.3)  other 
mesothelial  tumors  derived  from  the  serous  surfaces,  and  (4)  the  cisdo- 
thciiai  tuuiurs. 


MESOTHELIOMA 


275 


I.  Urogenital  Duct  Tumors.— WhethiT  the  urogenital  ducts  gain 
a  xcoiuiiin  lining  of  hypohlarit  or  opihiast  or  whether,  because  of  their 
MTV  tiirly  (iitferentiation,  the  properties  of  their  mucous  Hnings  are 
riliitiM'ly  stable  and  fixed,  certain  it  is  that  the  tumors  derived  from 
tli.Mi  are  usually  of  a  purely  lepidic  type-true  adenomas  and  true 
can  iiiomas— with  very  little  tendency  to  take  on  secondarily  hyloma- 
toMs  (siircomatousj  development.  Thus,  in  the  uterus  and'  prostate, 
li>r  .  \aini)lc,  we  get  pure  adenomatous  and  carcinomatous  growths! 
\vt,  though  rarely,  it  does  happen  that  a  tumor  of  one  of  these  areas 
may  show  most  marked  hylomatous  characters  (as  in  one  of  our  cases  of 
prostatic  tumor  where  the  primary  growth  was  typical  carcinoma,  but 
tlic  extension  sarcoma-like,  in  the  judgment  of  some  well-known  patho- 
idsrists).     Such  tumors  have  clearly  transitional  properties. 

1'.  Tumors  of  the  Ovary,  Testis,  Adrenal,  and  Kidney.— In  con- 
>i(lcriiig  the  tumors  of  the  kidney,  it  is  necessarv  t  j  remember  that  the 
Wolffian  duct  provivles  the  distal,  collecting  part  of  the  tubule,  and 
the  nicsenchyme  the  glomerular  epithelium  and  that  of  the  main  part  of 
the  tubule.  In  the  ovary  and  testis  the  primitive  kidnev,  intimately 
connected  with  the  Wolffian  duct,  is  involved,  along  with  the  germinal 
inesothelmm.  Thus  it  comes  that,  while  in  these  organs  we  meet  pure 
adenomas  showing  no  sign  of  reversion,  we  also  find  a  series  of  transi- 
tional tumors  which  in  places  appear  to  be  adenomatous  and  in  other 
places  sarcomatous,  and  yet  other  areas  where  one  passes  into  the  other 
and  the  cells  in  the  sarcomatous  areas  may  even  be  spindle  shaped' 
Mich  tumors,  once  for  all.  dispose  of  the  idea  of  the  strict  bounds  that 
were  tonnerly  supposed  to  exist  between  carcinomas  and  sarcomas,  and 
tliat  such  tumors  can  exist  is  due  to  the  common  embryogenv  of  the 
I>rinntive  tissues.  ' 

Adrenal  Tumors.— It  has  been  said  that  there  are  in  the  ovar\-,  testis 
Mil.  ki.lney,  tumors  of  fxed  type,  which  fixity  is  perhaps  due  to  the 
stahihty  ot  the  W olffian  epithelium.  Tn  the  adrenal,  however,  there  is 
no  Mich  (  oubttul  origin,  and  yet  we  f  n.l  in  it  transitional  tumors. 

I  li«'  ndrcnal,  it  is  true,  arises  from  two  sources:  the  medulla  originates 
111  ".nneotion  with  the  sympathetic  nervous  system,  the  cortex  from 
nuM.thehal  elements.  In  the  mwlulla  originate  tumors  that  are  true 
I  'iromas  with  rudimentary  ganglion  cells  and  non-medullated  fibres 
^^liKh  evidently  arise  from  cell  rests  of  the  sympathetic  system;  the 
•"rtical  tumors,  however,  are  entirely  different. 

Iir>t  there  are  accessory  adrenals;  they  are  composed  of  cortical 
"  '■«■.  lying  in  the  adrenal  capsule  or  in  the  adrenal  itself  or  outside 
'  ■  -T  even  in  the  kidney  and  more  rarely  in  the  liver,  while  at  times 
"'|,^  liaxe  I.een  earned  down  in  development  and  appear  in  the  ovary 
y  '<-tN.  U  hen  such  are  found  to  hypertrophy,  we  deal  with  an  adent^- 
";""n.>  phenomenon.  These  tumors  show  the  typical  cortical  tissue, 
■■"',,„  ot  cells  lying  „,  a  meshwo  x  of  capillaries,  the  cells  <ontain- 
-  ^it  and  myelin  droplets.  At  times,  instead  of  small  grow:hs,  we 
"  iiiniors  ot  large  size,  in  which  we  have  the  normal  appearance  of 


276 


PROGRESSIVE  TISSUE  CHANi     S 


!'iP 


m: 


w 


columns  of  cells,  the  cells  large,  and  crowded  with  fat  and  fat-like 
globules  and  glycogen,  which  last  is  constantly  present  in  the  growing 
adrenal.    Such    tumors,    again,    are    evidently    adenomatous.    But 


Fio.  127 


Fia.  138 


From  thi^  etige  of  a  small  iii-iliiic  nf  new 
growth  in  the  adronul  cortex.  shi>wiiiK  I'vcry 
transition  from  n,  cpIIs  UPdistinxuisliublo  from 
the  Burroundinn  cplls  of  the  cortex  to  small 
cells  with  deeply  staining  nuclei  of  sarcomatous 
lype.     (Adami.) 


similar  conversion  or  mo<lification  of  icir- 
lical  cells  of  adrenal  into  tumor  cells, 
(WfKjlley.) 


Hypernephroma  of  kidney.  Transition  from  adenomatous  to  sarcomatous  type  of  urowth:  ii'inJ'. 
adenomatous  oviTgrowth  of  solid  columns  or  masses  of  cells  of  adrenal  type;  iihm".  transition  to 
sarcomatous  arrangement;  A",  a  kidney  tubule  involved  in  ihe  growth.     (Dcbcrnardi.) 

there  are  other  tumors  which  in  parts  may  he  like  these,  and  in  other 
parts  show  cells  smaller,  less  fatty,  more  deefily  stained,  with  transitions 
fro.a  adenoma  to  sarcoma,  and  definite  sarcomatous  tissue;  these  may 


MESOTHELIOMA— ENDOTHELIOMA 


277 


slu.w  metastases  that  are  clearly  sarcomatous.  All  these,  lo  use  the 
tiKKltrii  expression,  are  homotopic  hjrpemephromM  (h.v|)ernei)hros,  the 
a(ircnai).    The  name  hypernephroma  is  more  commonlv  employ«l  in 

.inotion  with  a  remarkable  tumor  of  the  kidney,  in  the  belief  first 
pn, pounded  by  Grawitz,  that  tumors  of  this  order  found  in  the  kidnev 
oriKiimte  froma.lrenal  cell  rests,  that  they  are  heterotopic  hyperaephromM.' 
It  cannot  be  said  that  there  is  a  complete  consensus  of  opinion  as  to 
tlic  nature  of  these  renal  growths.     Possibly  some  of  those  which  are 
fmnul  ui  the  kidney  cortex  arise  from  the  kidney  instead  of  the  adrenal 
that  IS,  arc  nephromas  instead  of  hypernephromas.    The  two  cortices' 
that  IS  of  the  kidney  and  the  adrenal,  are  somewhat  r.>lated  embryo^ 
K'lcally  so  that  tumors  arising  from  them  must  possess  closely  related 
",*'*'"»■.•,  ^'"''  '^''^^'  '^  supported  by  thelatest  workers  on  the  subject 
namely,  Wilson  and  Dayis.    When  such  a  tumor  of  the  kidney  tends 
t..  form  tubules  instead  of  solid  columns  of  cells,  its  renal  origin  is  a 
riasonal)le  supposition. 

Tliese  tumor,  are  apt  to  be  yascular,  the  cells  being  in  close  contact 
with  the  capillaries,  and  they  are  prone  to  hemorrhage;  metastases 
l.v  the  blood  stream  readily  occur,  and  especially  is  the  tumor  apt  to 
Sirow  h\-  continuity  along  the  yeins  to  the  yena  cava. 

A  useful  term  to  describe  all  these  transitional  tumors  of  the  adrenal 
kKlnoy,  oyary,  and  testes  is  mesothelioma. 

A  mesothelioma  is  thus: 

I.  A  tumor  arising  from  tissues  which,  while  of  mesothelial  origin 
piissess  in  the  adult  state  lepidic  characters.  ' 

riT  ^Jvu"  *'^P'^"'  **"*'  ^'  s'ow  growth,  it  is  an  adenoma. 

IIJ.  When  atypical  and  of  rapid  growth,  a  sarcoma,  although  transi- 
1 1. .lis  I K-t ween  adenoma  -    '  -.•-.  coma  are  to  be  seen . 

I\.  The  secondarie.    .;       .       natous 

•!.  Mesotheliomas     _^  Surfaces.-These   are  flat,   nodular 

t.iin..rs,  si.rea.i.ng  locall.%  er  tiie  pleura,  more  rarely  the  peritoneum 
or  iHTicardium  looking  ^o  tLe  naked  eye  like  a  localized  inflammatory 
'i"«k.;iiing  and  under  the  microscope,  like  a  carcinoma.  They  evidentlV 
arise  Irom  tiie  endothelium  lining  the  serous  cayity  affected.  A  relatiyelV 
■'>M-i(laiit  stroma  is  present,  containing  elongated  acini,  formed  of  irreg- 

■r  swollen   often  cubical  cells.     Here  we  deal  with  a  carcinoma-like 
i  nor  t>,at  has  originated  from  the  part  of  the  mesoblast  that  has 
T.||^<■l|  lip  a  liiiinjr-mcmbrane  function. 

t   Endotheiioma.-The  endothelioma  is  a  tumor  arising  from  the 

'  n^  «lls  of  a  vessel,  ana  may  be  a  hemangio-endotheUoma,  from  a 

o  Vessel,  or  a  lymphangio-endotheUoma,  from  a  lymph  vessel;  in  a 
""  r  of  long  establishment  it  may  be  difficult  to  make  the  distinction. 

'  M-nssing  overgrovvths  of  blood  vessels,  we  have  to  consider  first 
J'    '.ma!  ones,  and  this  leads  us  to  the  consideration  of  some  tumors 
'■  ^'  ire  not  blastomas,  along  with  some  which  are 

■iu;rr!!rsti;^nJr^rr"t'^  angiomas  (tumors  having  vessels  as  their 
"■"■.u.nstituent).  whether  hemangiomasor  lymphangiomas,  arenot  true 


278 


PROCRESSIVE  TISSrK  C II. WOES 


l)l)istoinu.H;  ////•//  /«).w.w  no  jmwrr  of  iudeiH-iidnii  (jwuth.  Mt-rc  (liliitat ion 
of  spiins,  fvoii  if  pmrded  In  aplasia  and  fulJowtMl  hy  atr()|)liy  of  tin- 
siirr()uii(liii>;  tissues,  is  not  Krowtli;  nor  I  the  iiitToasi'  m  length  of  a 
vessel  (as  in  a  cirsoid  aneiirysni),  nor  im-rease  in  tlu>  tliiekness  of  walls 
(as  in  cavernoma)  to  he  considered  as  more  than  physioloKical.  We 
find  widening  of  preexistent  vessels,  either  congenital,  due  to  a  lack 
of  c(M)rdination  hetween  the  amount  of  tissut-  lo  he  supplied  and  of 
vessels  to  supply  it,  or  postnatal.  <lue  to  ohstruction  (as  in  hemorrhoids) 
to  compensate  for  which  the  capillaries  undergo  dilatation.  But  this  is 
not  hiastornatous  growth.  IVoperly,  most  of  what  are  called  angiomas 
are  angi«ctues,  or  dilatations  of  vessels  produced,  not  hy  virtue  of  inde- 
pendent (ill  growth  but  hy  some  physical  force  or  "other  stimulus. 
The  angiomas  proper  will  he  dealt  with  later. 

liluixl  Vitscuhr  Tumors  ("Ilemanglumas")  which  are  not  lilastonm," 
—1.  Obstructive  Telangiectases.— The  hest-kn(,-.vn  example  of  this  is  the 
hemorrhoid.  The  hemorrhoidal  veins  of  the  anal  region  communicate 
with  the  main  and  with  the  portal  vejious  system;  situated  close 
to  the  surface  and  poorly  supported  externally,  obstruction  to  the 
onward  passage  of  blood  leads  to  dilatation.  Similar  capilli  rv  nid  venous 
dilatation  occurs  in  "nutmeg"  liver,  in  the  vessels  of  the  nose  and  cheek, 
and  in  the  frequently  observed  varicose  veins  of  the  legs. 

2.  Aneurysm. — This  is  the  dilatation  of  an  artery  produced  as  a 
result  of  weakening  of  its  wall.  The  only  form  of' aneurysm  which 
might  at  all  be  considered  as  angioma-like  is  the  form  known  as  cirsoid, 
which  may  show  itself  at  birth  and  grow  rapidly  afterward,  having  a 
tortuous,  worm-like  appearance,  and  sometimes  reappearing  in  the 
same  region  after  removal.  It  is  probably  due  to  a  combination  of 
congenital  weakness  of  the  wall  with  inadequate  discharge  of  hiiMxJ 
from  the  vessel. 

3.  Ck)ngenital  Telangiectases. 

(a)  Tilanuiedatic  iWr/.— Some  nae\i  (pigmented  moles)  arc  purely 
cutaneous  t)utgrowths  with  melanin-containing  cells;  the  majority 
contain,  in  addition,  dilated  capillaries  or  may  indeed  he  areas  of 
simi)le  telangiectasis  ("birthmarks").  The  "blue  naevus"  is  an  extreme 
grade  of  the  same  condition,  often  very  extensive.  The  association 
of  telangiectasis  with  congenital  pigmentary  disturbance  suggests 
that  we  arc  dealing  with  a  vice  of  develoixneiit;  the  simple  birthmark 
is  a  cai)illary  dilatation,  and  the  same  state  may  be  found  in  hone, 
muscle,  or  even  in  the  brain.  The  bhie  na-vus  has  larger  spaces, 
where,  by  ])ressure  atrophy,  septa  ha\-  been  broken  down,  while  tlie 
septa  that  yet  exist  and  the  contaiinng  capsule  indicate  overgrowth 
from  pressure — stress  hypertrophy. 

(b)  Cnvernoma.—TWi'A  form  can  scarcely  be  separated  from  the 
foregoing,  and  is  a  frequent  abnormality  of  the  liver,  in  which  it  is 
found  most  frequently  of  the  size  of  a  pea,  although  occasionally  as 
large  as  an  orange.  It  is  suj)pose(|  but  not  certainly  known  that  '^oiiie 
are  congenital,  while  in  others  it  may  be  that  a  localized  atrophy  of 


ESDOTIIKLIOMA 


279 


lij.T  .ells  is  followwl  l,y  c()m|)en.sat..ry  .lilutatl,,.  of  the  eapillaries 

Ml.  r..sr,.|..,.ally,  a  <avernoma  <onsists  „f  lar^e  irreRiilar  bl.KHl  spaces! 

(oiiiiiimncatiiiK   one    with    aiiotluT,    liiietl 

li.\   iridotheliiiin    and    haviii);   septa  (»f  u  fi...  i.n 

filiroiis   nature,   in  which   often   are  seen 

|ii^,'int'nt   particles.    Throinl)osis  or  calci- 

fif  ition    with    formation    of    phleholiths 

|>i'iir>  in  them.     Their  congenital  origin 

is  a-crihed  to  the  failure  of  the  original 

c'lipilliiries  to  become  clothe<l  with  or  to 

Fio.  130 


<':l\'TIMtri);i 


i)f  liviT.     CimsK  appcaranre.     (After  Riliborf.) 


Sccliim  <if  »niall  ravprnnnia  of  liver. 
»li(i»inK  the  cavernous  aii<l  ciiiiinjuni- 
intiriK  vu«.ular  i.parc»,  from  whirh  Hie 
liliMiil  liu«  been  removed.     (Ribbert.) 

enter  into  connection  with  liver  cells;  and  a  strange  fact  has  been  noted 
Mimuh ,  that  they  are  not  connected  with  surrounding  capillaries, and,' 

Fia.  132 


"■  -       ■■  I    ai  J  ;  '■';;"■"   •■'"'';""•''"'  '•••"»•  «'"'•''  i"  P""».  »«  ut  ..  forn.  «.|W  „^,; 

'.  I  irm  rami  c,  smaller  bloodvessels.     (I)riess..n.)  -"^es. 


^'    !;n:.'  t"  Uihbcrt.  c;.iinot  be  injecteil  through  ilie  hepatic  vein.   Most 
^y  show  no  sign  of  independent  growth  and  are  not  blastomas. 


'.I'«ftf5»^" 


2S0 


PROCREfiStVE  TISSUE  CHANGES 


True  Typical  BUstonutoua  HeinuiciomM.--Aii{iom»  Simplex.— Tli 
true  angioniu  sIkavs  an  lutnul  prolifi'Ditioii  of  capilluries  with  soni 
ectasis,  and  tlio  striking  fratnre  is  thv  fiidotlit'liiiin,  wliieh  is  larjt( 
rich  in  cytophisni,  and  often  more  than  one  laver  deep.  These  hav 
been  found  in  the  skin,  chorion,  and  muscle,  and  the  tumor  consists  r 
a  congeries  of  such  prohferated  endotheUal  tuhulcs-  sometimes  calle 
the  l>eiiiKn  angioma.  Cases  which  show  <leparture  from  the  type  eve 
to  the  extent  of  showing  cohunns  of  cells  instead  of  tulniles  ought  t 
he  classe<l  with  the  hemangio-endotheliomas — the  atypical  angiomas 
much  in(»re  so  when  they  exiiihit  metastases.  In  the  endothelii 
growth  we  see  the  one  main  factor  which  makes  these  blastomas. 

Vw.   133 


Section  from  a  case  of  hcmangirum  -implex,  exhibiting  progressive  enlargement  and  extension, 

U  orrmunn.) 

Lymphangioma. — Here,  as  in  the  hemangiomas,  the  majority  ol 
tumors  called  lymi)hangiomas  are  really  lymphangiectases.  Tliest 
may  he  independent  or  may  occur  in  connection  with  tumor  growth, 
in  which  case  the  angiectasis  is  subordinate  to  the  tumor  growth; 
dilated  lymph  channels  are  often  seen  in  connection  with  all  forms  oi 
overgrowth.  When  independent  and  unassociated  with  neoplasms  of 
other  orders,  lymphangiectasis  may  be  inherited  or  acquired,  and  is  one 
of  three  grades,  between  which  occur  all  stages  of  transition. 

1.  Simple  Lymphangiectasis  ("lymphangioma  simplex").— These  occur 
congenitally  as  slightly  raised  areas  upon  the  skin  breaking  through 


ENDOTHELIOMA 


281 


easily,  atui  when  broken,  "weepinj?"  persistently  (lymphonhoB*).  They 
(iiciir  most  frequently  on  the  face  and  neck,  and  v^ry  greatly  in  the 
(Itptli  they  extend  into  the  tissue.  Anatomically  like  thew/bii  ac- 
•liiiriil.  are  the  dilatations  of  lymph  channels  secondary  to  obstruction 
tliiit  arc  found  in  elephutlMli  (filarial). 

Fio.  134 


^ 


S. ,  ti„n  frnm  a  lyn.phangieot.tic  polyp  of  the  now.  .bowing  the  greatly  diatendcd  lyinp»-  chanoeb 
liui.l  by  delicate  endothelium  and  the  adematoua  interatitial  tinaue.     (Hifrb  power.) 

2.  C'-.ve.Tious  Lymphanpectaais  ("Lymphangioma  cavemosum").— These 
"TrcspuMd  to  the  caNernomas  but  contain  lymph,  not  blood;  mostlv 
<oiif;emtal,  they  include  examples  of  macro(lo88ia  (enlargei-.  ^t  of  the 
'oiifjiie),  macrocheiUa  (enlargement  of  the  lip),  and  othe.-  t-.-nis  oi 
'"NjTiiital  elephantiasis,  brought  about  by  a  defective  ability  of  the 
ti>-|ii('s  to  (ii-eliarge  the  lymph. 

;i.  Cystic  LymphangiectJwis.— The  most  striking  examples  of  this  are 

""|"I  Ml  eases  of  "cystic  hygroma,"  where  multiple  large,  clear  cysts 

""iir  hdow  the  ear,  or  submn:dllary,  or  above  the  clavicle.    The 

«'  ilinj;  is  tense,  and  the  large  cysts  often  do  not  communicate  with 

''''•yn.,,tht.r;  tlu-y  a  e  lined  with  endothelium  and  have  strong,  fibrous 

■  p  I  lis  is  not  due  merely  to  obstruction,  but  the  secretory  activitv 
;>'  1  He  eiMlotlielmin  is  likewise  responsible.    Not  to  be  confounded  with 

->  cervical  hydrocele,"  where  a  cyst,  lined  by  epithelium,  arises  from 
I'  n  nt  a  eervical  duct  or  fissure.  A  true  hygroma  may  appear  in  the 
'  a7    •''*'T"i'  "  '"™  ^^  ^^"^  congenital  sacral  tumor. 

tvpical  Angiomas.    Hemangio-endotheUoma.— The  most  character- 
-  >  >  ^aIlll,lt■  i>  that  developing  beneath  the  dura  mater,  where  it  forms 


282 


PROGRESSIVE  TISSUE  CHAXOKS 


I!? 

;  i 


II 


nofliiles  tliat  displace  hraiii  substance  or  spread  as  sessile  masses.     TI 
uppearunce  of  the  inicrosc(»pic  field  is  strikiiij;;  the  tissue  consists 

ruinierous  whorls  of  concentrical 
disposed  cells,  which  are  flattent 
but  not  tightly  i)acked,  especial 
at  the  centre,  where  one  may  oft( 
distinguish  the  lumen  of  the  blo( 
vessel.  If  cut  in  a  direction  m 
jjcrfectly  transverse,  the  mass( 
ai)pear  oval  or  curved,  and  in  an 
case  there  may  be  between  them 
good  deal  of  cellular  fibrous  tissm 
The  whorls  may  show  hyaline  r 
calcareous  change,  in  which  last  ca; 
the  tumor  is  called  a  psammomi 
,  ^  ,  The  psammomas,  sometimes  mu 

Hiiiianitiii-tnilothclKmia  from  nose  of  child       .  •    i  j.        u  I  i 

(Dr.    KIntz),  showing  devolopment   of    new      ^'P'^'    aPPCar   tO     liaVC    alwayS   thl 

capillaries  (o).  endothelial  origin  and  the  rapidi 

growing  ones  are  sarcomatous. 

Lymphangio-endothelioma. — ^Vben  there  is  no  perfect  whorling  c 
cells  around  the  capillaries,  growths  of  this  nature  may  be  considere 
as  arising  from  the  endothelium  of  lymph  channels. 


S«i-iion  froir.  a  pirilhi'lioma  or  perithelia!  angiosurcoiiia  (from  the  eolleetion  of  Dr.  Rhea)    .ihomni 
the  relationship  of  the  central  bluo<l  vessel  a  to  the  new  growth. 

Perithelioma.' — Tumors    are    sometimes    found    showing  capillary 
chainiels  cut  in  various  directions,  lined  by  endothelium,  around  each 

'  Many  object  to  this  term:  it  is  perniis.sible  if  understood  as  an  abbreviation  foi 
"perivascular  lyniphangio-endothelioina." 


^^'f^l^ 


ENDOTHELIOMA— MELA  XOMA 


283 


(if  wliich  channels  is  a  collection  of  cells,  many  layers  deep,  arranged 
rmlially.  This  arrangement  in  rows  at  right  angles  to  the  capillary 
axis  IS  characteristic,  and  has  led  to  the  snpposition  that  thev  arise 
from  ti)e  endothelium  of  the  perivascular  lymph  channel.  Tlie  cells 
farthtst  from  the  vessel  are  evidently  the  oldest  and  probably  from  this 
cause  are  the  most  likely  to  degenerate;  hyaline  change  in  such  areas 
j;i\es  perfect  examples  of  the  cylindroma— a  term  used  to  designate 
these  and  allied  tumors  that  are  formed  of  a  collection  of  cylinders. 
ea(  h  eyiinder  being  a  mass  of  cells  surrounding  a  lumen,  and  themselves 
siirn.iinded  on  the  outside  by  a  zone  of  hyaline  change. 

Fio.   1.37 


-•in. .11  fri.m  iin  alveolar  niplanoma  or  chromatophoroma  of  tho  urpat  to,-.  The  opIIh  in  Roneral 
r.  i..  r.  M.,.|i  I,,  hi.  fre..  from  iiiplanin  Kraniilos,  but  thew  arc  pri-soiit  in  orcasional  rella  both  of  tho 
"'...I  ..,1  anil  of  the  stroma  (fc).    At  r,  som..  of  the  molnnin-rontaining  wIIh  are  drawn  separately. 

Via.  138 


Ihea)    ahowing 

1  .. 

'  capilhiry 
ound  each 

It 

ill 
an 
Ti 

reviation  for 

CI. 

iir 

PiKnicnt-iontaininn  rrlls  from  a  spimllc-oelled  melanoma.     (Hibberf.) 

Melanoma.- There  is  a  great  deal  of  uncertaintv  about  these  tumors, 
' '  ll  are  characterized  by  the  presence  of  chromatoi)hores,  that  is, 
1  ^^lii.h  l)ear  pigment,  whether  they  be  in  the  skin,  the  mucous  mem- 
•'■'e-,  or  the  ehoroul  of  the  eye.  These  cells  are  found,  normallv, 
"I'-  skill  of  tile  anal  region  or  the  pigmented  areola  of  the  breast, 
I  'Mst  in  the  pigmented  warts  that  are  so  common  on  the  skin. 
'  I'l^inent  is  melanin,  an  iron-free  protein  «r protein  (Icrivative  often 
■  ' ' nmg  sulphur.  We  do  not  know  surely  if  these  cells  are  epiblastic 
'  ■  "i)lascic  in  their  origin,  whether  they  are  epithelial  or  supportive 


284 


PROGRESSIVE  TISSUE  CHANGES 


in  their  nature,  and  sonic  of  the  tumors  are  alveolar,  sui^^f -^ting  a  car- 
cinomatous origin  (Fijj.  I'M),  others,  more  particularly  those  arising 
from  the  choroid  of  the  eye,  are  non-alveolar,  with  cells  of  the  type  of 
a  spindle-celled  sarcoma  (Fig.  \',]H).  The  tumors  vary  in  color,  from 
white  (especially  secondaries)  to  hrown  or  black  afcording  to  the 
amount  of  pigment  present ;  they  are  highly  malignant,  and  the  second- 
aries are  apt  to  be  exceedingly  abundant.  Microscojjically,  as  above 
noted,  the  growths  differ  greatly.  The  most  likely  explanation  of  their 
varying  properties  is  that  one  kind  of  cell,  the  chromatophore  mother 
cell,  of  lyraphangio-endothelial  origin,  gives  rise  under  different  condi- 
tions of  vegetative  activity  to  carcinonni-like  or  sarcoma-like  tumors. 


Fia.  139 


JC. 


x^ 


Tumor  of  piriihelioniatoua  t.\po  of  the  carotid  glaiid:  O,  vessels:  W/,  hemorrhage  into  a  cohimn 
of  Pells;  at  tl  tiie  eella  of  the  growth  are  tukinK  on  a  more  eoniiective-t issue  type;  at  c,  hyaline 
degeneration. 

Other  Tumors  of  Doubtful  Relationship. — Cholesteatoma.-- -This  is 
found  especially  related  to  the  membranes  of  the  brain,  and  is  charac- 
terized by  the  presence  of  pearly  nodules.  The  cells  are  of  epithelial 
or  endothelial  type  and  among  them  may  be  cholesterin  crystals.  1  liey 
are  by  most  considered  as  endotheliomas,  but  the  finding  of  hair  follicles 
makes  this  not  so  clear.  The  name  is,  unfortunately,  most  commonly 
applied  to  a  tumor  found  in  the  external  auditory  meatus  and  the 
middle  ear,  which  is  not  a  blastoma,  but  a  condition  allied  to  hyper- 
keratosis, an  accumulation  of  flattened  epithelial  cells,  which  have  not 
been  cast  off. 


T^uZTrij 


A  THEORY  OF  NEOPLASIA 


285 


Tiunors  of  the  Carotid  Oland. — The  nature  of  the  "carotid"  gland 
iRiiifl  (il)scure,  it  might  be  expected  that  the  .  ature  of  the  tumors  arising 
from  it  w(;uld  also  be  obscure.  These  are  at  tini;  *  like  the  peritheliomas 
iiiid  the  sarcomas.  Similar  difficulty  is  found  in  the  i .  .;e  of  the  coccygeal 
gland,  and  the  perithelioma-like  tumors  that  arise  from  it. 


A  THEORY  OF  NEOPLASIA 

It  will  be  evident  from  the  foregoing  that  some  growths  owe  their 
oriiiiii  to  cell-rests;  such  are  the  teratomas  and  the  teratoblastomas,  the 
tiiniors  originating  from  persisting  rudiments  of  embryoiiic  structures 
luill  clel'ts  or  branchial  cartilages),  and  ;rom  cells  displaced  during  the 
course  of  development  (aberrant  hypernephroma,  columnar  carcinomas 
ill  regions  where  squamous  epithelium  normally  exists,  etc.). 

Tlie  idea  of  cell-rests  has  been  known  for  long  by  Cohnheim's  name, 
liut,  useful  as  it  is,  it  gives  no  clue  to  the  reason  why  tumor  growth 
springs  up  from  one  cell-rest  and  not  from  another;  even  on  (\)hnheim's 
line  we  may  go  farther  and  say  that  new  growths  arise  also  from  cells 
wliicli  ha\e  undergone  7tot  congenital,  but  jx)sinntal  displacement,  as 
liapiH'iis  i  squamous-celled  carcinoma  arising  in  a  scar,  or  in  columnar 
carcinonia  from  the  edge  of  an  ulcer.  But  cell  displacement  if  not  the 
I'tificiififd.  Indeed,  certain  neoplasms  arise  from  provedly  undisplaced 
cells,  and  by  actual  transformation  of  the  tissue  cell  into  the  tumor 
cell.  'I'lnis  has  been  described  the  change  of  liver  cells,  the  cell  losing 
nnicli  of  its  nuclear  chromatin  and  becoming  granul«r,  then  an  enlarge- 
ment of  the  nucleus,  and  a  final  acquirement  of  abundant  protoplasm. 
Mil  longer  granular;  and  all  this  happens  while  the  cell  is  ctill  connected 
toils  fellows.  This  is  the  jirocess  we  have  referred  to  as  undifferentiation 
or  anaplasia.  It  is  by  a  process  of  change  like  this  that  we  can  under- 
stand the  blastomatoid  growths,  which  develop  not  from  a  single  cell 
l)nt  hy  a  generalized  proliferation  of  the  specific  elements  of  a  tissue, 
tlic  i)histomatoid  cells  showing  all  gradations  from  simple  hypertrophy 
to  i)runoiniced  malignancy.  A  general  theory  upon  which  to  base 
nci  li.l.isia  has  been,  for  example,  to  consider  it  as  the  result  of  the  removal 
of  tissue  restraint,  while  less  widely-reaching  suggestions  have  been 
tlic  attetn]!  to  show  a  parasitic  origin  for  all  neoplasms.  All  these 
fadors  may  oc  present,  but  no  one  is  adequate  to  explain  all  cases. 
Ah  adequate  explanation  will  have  to  show  some  influence  always 
pii  Milt  in  the  cell  itself,  rather  than  an  external  stimulus  or  a  series 
of  external  stimuli. 

The  Habit  of  Growth.— We  have  attempted  to  show  that  cell  life 
1-  dependent  upon  the  never-ceasing  activity  of  exchange  between 
li'ideiis  and  cytoplasm,  between  cytoplasm  and  food,  between  nucleo- 
pl  i-ni,  cytoplasm,  and  the  detached  ions  that  mean  ferment  action; 
e!trg\  can  be  expended  in  the  direction  of  growth,  of  function,  and 
oi  [iruliferation,  the  last  orciirring  when  a  certain  physiological  degree 
<•:  growth  has  been  attained.     If  now  cells  be  placed  so  that  no  function 


280 


PROGRESSIVE  TISSUE  CHANGES 


ill 


is  (iemaiulcd  of  them  or  pennittt'd  to  tliem,  while  they  coiitimie  to 
gain  noiirishiiieiit,  tliev  may  remain  vegetative  or  become  vegetative, 
and  acquire  a  hahit  of  j;ro\vth,  losing  the  habit  of  function  The 
mere  existence  of  immature  cells  or  of  cells  that  have  passed  from  j, 
difTcri  itiated  form  to  a  less  diti'erentiated  form,  is  not  enough;  colls 
must  assume  this  habit  of  gn  >vth  and  lose  the  habit  of  function 
before  they  can  originate  a  neoplasm.  A  cell  that  is  ready  to  be  the 
starting-point  of  a  neoplasm  diti'ers  from  an  embryonic  cell;  the  latter 
has  the  ])otentiality  of  dirterentiation  still  before  it,  the  former  has  lost 
it.  As  suggesting  how  tlie  cell  has  lost  it,  we  ])ut  forward  Oertel's 
hypothesis  that  as  in  the  protozoa  we  find  in  some  cells  two  nuclei,  one 
associated  with  rei)roduction  and  the  other  with  the  functional  activity 
of  the  cell,  so  in  man  and  the  metazoa  there  is  chromatin  of  two  orders, 
of  which  one  governs  the  i)roliferative,  the  other  the  functional 
cai)acity  of  the  cell.  A  tumor  cell  is  a  cell  that  has  largely  lost 
the  latter;  when  lost  the  cell  is  unable  to  replace  it.  Such  a  cell  can 
give  rise  only  to  daughter  cells  that  lack  this  power  of  dift'erentiation, 
but  are  still  endowed  with  full  vegetative  properties.  That  such  is 
the  case  is  not  yet  i)roved,  but  the  idea  is  worthy  of  preservation  in 
tlie  i)resent  state  of  our  knowledge.  It  seems  necessary  to  recognize 
among  the  blastomas  some  change  in  the  biological  i)ronerties  of  cells 
as  an  essential  for  neoplasia.  It  is  not  something  outside  the  cell, 
neither  an  external  stimulus  nor  a  diminished  external  resistance;  it 
may  be  that  an  external  stimulus  starts  tl  j  cells  on  that  path  which 
leads  eventually  to  their  assuming  neoplastic  properties;  it  may  even 
be  thot  the  malignant  growth  affords  a  secretion  which  depresses  the 
vitality  anrl  inhibits  the  growth  of  surrounding  tissue  cells,  but  these 
are  subsidiary.  The  essential  point  is  that  the  cells  giving  rise  to  an 
autochthonous  new  growth  are  so  modified  that  the  energy  acquired 
by  the  accumulation  of  food  is  not  discharged  in  the  performance  of 
function,  as  in  the  healthy  cell  in  normal  relationship,  but  is  retained 
and  accumulated  only  for  purposes  of  growth  and  multiplication. 
This  is  far  from  denying  tiiat  various  stimuli  assist  the  modification 
of  the  cell;  it  may  be  that  in  one  case  the  cell's  position,  displaced  as  it  is, 
tends  to  retard  its  function  but  not  its  vegetation,  or  in  another  case 
that  a  micTobic  or  parasitic  agent  begins  an  inflammation  that  acts 
similarly,  or  in  yet  another  case  that  a  senile  loss  of  function  paves  the 
way,  the  change  being  accompanied  by  ;in  alteration  in  histological 
characters.  There  is  not  oiic  specific  agent,  but  many  and  these  at 
the  most  begin  the  process.     The  end-result  is  a  cell  mutation. 

What  is  the  i)ractical  bearing  of  this?  It  is  that  the  cure  of  cancer  does 
not  lie  in  the  discovery  of  a  parasitic  ?ause,  for,  judging  by  what  we  know 
of  the  nature  of  malignant  cells  the  mere  removal  of  a  microbic  or  ])ara- 
sitic  cause  will  not  suffice  to  stop  cell  activity  and  the  propagation  of 
the  properties  that  the  cells  have  assumed.  We  have  rather  to  seek 
agents  that  will  influence  the  growing  powers  uf  these  cells.  Two 
possibilities,  at  least,  lie  open. 


';;^raih 


CYSTS 


287 


The  first  of  tb(  se  is  <in  apparent  {)arallel  to  hacterial  immunity.  In 
tln'  iniKiilation  of  mouse  cancers,  it  has  bee i  found  that  successful 
iiKidilation  with  a  cancer  is  followetl  l)y  subsequent  failure  to  inoculate 
iijiiiiii  the  same  mouse;  two  simultaneous  inoculations  may  be  suc- 
cessful, but  if  one  be  successful,  a  subsequent  inoculation  fails.  Some 
sucli  inoculated  tumors  subsequently  shrink  and  disappear,  and  Ine 
iiiiinial  is  immune  to  inoculation  with  the  same  or  an  allied  tumor. 
These  i)henomena  are  evidently  due  to  the  produciion  of  antibodies 
l>y  till-  tissues,  parallel  to  that  seen  in  various  infectittns,  and  it  seems 
l>()ssil)lc  that  tumor  or  even  normal  cell  extracts  mighl  exalt  the  defences 
(if  tlie  body  against  tumor  growth.  Yet  we  must  not  be  blind  to  the 
fact  that  many  incjulable  tumors  induce  but  a  very  slight  general 
rc'ii'tid... 

The  second  mode  of  destruction  of  new  growths  is  ])arallel  to  the 
iinployment  of  the  agents  that  produce  passive  immunity.  It  may 
lie  that  drugs  or  animal  substances,  or  mechanical  af:rits  like  radium 
(ir  the  Roiitgen  rays,  chemicals  such  as  salts  of  selenium  and  tellurium, 
or  body  ferments  may  be  found,  to  which  the  neoplastic  cells  are  more 
s(ii>iti\o  than  are  the  normal  ce!is,  their  growth  being  arrested  and 
atrojiliy  and  absorption  ensuing.  As  a  matter  of  fact  it  has  been  fully 
(hinoMstrated  tiiat  radium  and  a^-rays  especially  arrest  the  activity  of 
\(i;ttati\e  cells.  As  this  work  has  been  passing  through  the  press, 
\Va>MTniann  has  aniunniced  partially  successful  inoculations  with  com- 
pdiind^  of  selenium  and  tellurium  with  anilvi  dyes:  these  ha-e  resulted 
ill  the  destruction  and  disapj)ea ranee  of  the  cancer  cells  in  mouse  carci- 
iKiina  witiiout  injury  to  the  tissues  in  general.  We  say  partially  suc- 
<V"fiil:  the  experiments  were  wholly  successful  in  the  case  of  small 
luinors;  with  larger  growths,  while  the  tumors  disappeared,  the  animals 
a|)i)arently  poisoned  by  the  products  of  tumor-cell  disintegration. 


(iii'il 


CYSTS 


Mil 


A  r\st  is  a  sharply  limited,  abnormal  collection  of  fluid  unprovided 
ih  a  (iiannel  of  outflow,  possessing  a  well-developed  boundary  wall. 

1-  ruimd  or  oval,  and  the  fluid  fills  it.  We  do  not  count  the  serous 
vitio  as  cysts  if  they  contain  fluid,  although  we  regard  those  serous 
'-.  (ailed  bursa?,  as  cysts  if  they  contain  a  marked  excess  of  fluid 
(I  the  normal  amount.  Cysts  are  tumors  only  in  the  sense  that 
I .    Mre  swellings;  they  are  in  no  sense  neoplastic,  and  the  wall  grows 

fiinrt  relationshii)  to  the  amount  of  the  fluid  content,  and  the 
!'  i"n  exerted  by  it. 

\' '  nnling  to  their  causation,  cysts  may  be  divided  into  the  following 
'"||'>:  (1,1  retention  cysts,  due  to  abnormal  dilatation  of  preexisting 
'ii!(N  of  the  organism  as  a  result  of  secretion  outstripping  absorp- 
-i  hemorrhagic  cysts,  dut^  to  escape  of  blood  into  the  tissues  and 
ipient  encai)sulation;  Qi)  necrotic  cysts,  due  to  the  death  and  lique- 


.-^rm^s^ 


288 


PROGRESSIVE  TISSUE  CHANGES 


m 


im 


faction  of  tissues  with  subsequent  encapsulation;  and  (4)  parasitic  cysts, 
due  to  the  development  (in  itself  normal)  of  metazoa.i  parasites  within 
the  organism,  such  jjarasites  possessing  a  cystic  stage. 

A.  Secretory  or  Retention  Cysts.— This  group  may  he  subdivicled 
according  to  the  nature  of  the  cells  lining  the  cysts  into  (1)  cysts  with 
cubical  or  columnar  "glandular"  epithelium,  (2)  endothelial,  (3)  epen- 
dymal,  (4)  squamous  epithelial,  and  (5)  composite  cysts. 

In  all  of  these,  when  cellular  activity  leads  to  secretion  into  a  cavity 
unprovided  with  an  outlet  or  when  the  outlet  is  obstructed,  the  fluid 

is    secreted     against    piessure, 
Fio.  uo  which,  while  low,  is  above  that 

in  thi  cai)illaries;  as  the  secre- 
tion Is  continuous  and  the  ah- 
sorjjtion  less  rajHd,  the  cavity  is 
gradually  distended,  and  under 
this  gradual,  not  excessive  strain, 
cell    multiplication   is   favored, 

Kici.  141 


Section  through  a  retention  ryst  of  mucosa  of 
under  aspect  of  epiglottis,  due  to  obstruction  of  a 
mucous  gland.  (Professor  Klotz)  (low  power  )  a, 
blood  vessels:  b,  compressed  acini  of  a  mucous 
gland:  c,  cartilage;  d,  artery. 


From  the  same  section  under  higher  magni- 
ficalion  to  show  the  flattened  epithelium 
liaing  the  cyst. 


and  not  only  the  lining  cells  multiply  but  also  the  underlying  coniiectjye 
tissue.  Eventually  the  lining  cfHs  become  flattened  by  pressure,  (Fig. 
141),  and  ill-nourished  by  reason  of  the  pressure  on  the  vessels  in  the 
walls,  so  that  atrophy  and  final  disappearance  may  result.  The  watery 
contents  of  the  ceil  sire  absorbed,  so  that  the  less  diffusible  products  (rf 
secretion  become  more  and  more  concentrated,  until  the  cyst  may  be 
filled  not  with  watery  fluid  but  with  inspissated,  thick,  jelly-like,  or 
colloid  content. 


■KilllMIII 


CYSTS 


289 


I.  Of  Antenatal  Ohuhn.- Congenital  Cysis  Due  to  Persistence  of 
I'lirh  ,if  Embryonic  and  Foetal  Ducts—TWis  is  a  large  frrouj).  In  the 
un.wtli  of  the  cml)ryo  and  foptns,  certain  passages  that  onlinarily 
hccoiiic  closed  and  atrophy,  may  not  become  completely  absorbed; 
tikse  rcriiiin  isolated  in  other  tissues,  and  either  immediately,  or  after 
years  iia^e  elapsed,  their  cells  may  take  on  secretory  activity,  giving 
oriu'iii  to  cysts.     Some  of  these  are  as  follows: 

[(I)  Thyrolingual  cysts  in  the  median  line  of  the  neck,  from  the 
thymlingual  duct  leading  down  from  the  foramen  ccecum  of  the  tongue 
to  the  thyroid. 

V)  Branchial  cvsts  on  the  side  of  the  neck,  between  the  angle  of  the 
jaw  and  the  stewioclavicular  articulation,  from  t!ie  branchial  clefts. 
The  contents  of  this  series  vary  from  mucous  flui«l  to  sebaceous  material 
according  to  whether  they  originate  from  the  inner  end,  lined  with 
mucous  membrane,  or  the  outer  end,  lined  with  squamous  epithelium. 

('  I  ViteUo-intestJnal  cysts,  near  the  navel,  from  the  omphalomesenteric 
duct  which  communicated  between  the  small  intestine  and  the  yolk 
sac. 

((!}  Urachal  cysts,  in  the  hypogastric  region,  from  persistence  of 
parts  of  the  urachus. 

(c)  Ci/xtn  of  the  Primordial  Gen ito-urinary  Passages  in  the  Female.— 
FIr.  1 12  will  serve  to  recall  the  relations  of  these  ducts  and  the  changes 
liy  whicli  they  arrive  at  their  finally  destined  purpose;  cysts  are  liable 
to  arise  from  imabsorbed  portions  of  those  that  atrophy.  Cysts  of  the 
Wolffian  body  are  apt  to  be  multilocular,  growing  in  the  broad  ligament. 
Tysts  arise  from  the  lateral  (free)  tubes  of  the  paroophoron;  thev  are 
of  siiiall  size.  The  cysts  that  arise  from  the  connp?ting  tubes  of  the 
iwroiiphoroii  (connecting  with  the  ovan)  may  be  of  large  size;  they 
are  often  single,  and  are  lined  by  various  kinds  of  epithelium,  though 
tins  may  be  lacking  in  the  larger  ones,  where  also  cholesterin  mav  be 
toiinil.  Cysts  of  Gartner's  duct  occur  in  the  broad  ligament  and  in  the 
vajrinal  \yn\\.  Hydatid  of  Morgagni  is  the  term  which  describes  the 
nstic  dilatation  of  the  long  fimbria  of  the  Fallopian  tube. 

i.fi  ry/.s/.v  o/  the  Primordial  Genito-iiriyiary  Dncts  in  the  Male.— 
Stalked  hydatids  are  found  at  the  upper  pole  of  the  testis  arising  from 
WoHhan  tul)nles.  Encysted  hydrocele  of  the  testis  may  arise  from  the 
^iisi  (ti(rentia,  while  from  the  Miillerian  duct  may  arise  at  its  distal 
ciKl  a  sessile  hydatid,  a  cyst  in  connection  with  the  globus  major  of  the 

Cl)l(|l(|y|i|is.  '' 

ifn  rnniirnitul  Cy.sts  Due  to  Arrested  or  Imperfect  Development  of 
i.laiuluim-  (hf/ans.— This  class  is  well  exemplified  bv  the  congenital 
cystic  kidney.  I„  the  formation  of  this  organ,  the  glomerulus  and  the 
mHii,  proper  arise  from  the  mesoblastic  nephrogenic  tissue,  while 
tiie  coliretmg  tubules  take  origin  from  the  Wolffian  duct.  When  a 
proper  iimetion  between  the  tubules  from  these  two  sources  fails,  the 
Jei" '"  '"""  "'""^'^  distends  the  upper  parts  of  the  tubules  and  cysts 
lit 


' -=w»  .  I     ..c 


1  'S.^.'^CA  '* 


290 


I' Ron  II  ESS  I VK  rissi'E  cuaxoks 


III 


II.  Ok  Postnatal  Omc.is.  ].  Orinlndfiiitj  in  Tiihuhtr  (Unmh 
ihrnufih  OI>»tnictii>ti  of  their  Duds.-  Tlit-sf  art-  the  ordinary  "retention" 
eysts,  arising  from  pluKjii'iK  <>f  the  duct  hy  mucus,  or  a  calculus,  or 
from  stenosis  of  tlie  iluct  fntm  previous  injury  or  i)y  the  prrssure  of 
surroundinj;  fihrons  tissue  or  of  near-hy  new  jjrowtli.  Examples  are 
very  numerous;  ranula  of  the  floor  of  the  mouth  from  obstruction  of 
the  suhlinnnal  thict  or  that  of  tlie  ijlamliilu  incisiva  somewhat  in  front 
of  it;  salivary  cysts  from  hlockinj:  of  a  saHxary  duct;  mucous  cysti 


Fid    112 


m 


J\i  ro(V/>/ioi'(>?i  or 

ycpiifif  lit. of 

M'ulffiu'i  Biitly. 


Iirua 


I. 


II 


S  ,:    a  a  _ 


i  o  -I  s  B 


I'diailidijini 
yephrif  lit.  I'f 
Wolffian  Holly- 


III. 


'{plationsliip  i,!  the  sixii:il  iliiil.s  and  tijiir  ruiliiiirnts  in  tin-  luci  sixis:  /,  Ihc  indifFircnl  priniars' 
typo.  //,  thf  iliflcrcntialiori  in  llic  fi'nialf.  ///,  Uic  iliffcrcntiation  in  llie  male.  Ilyd  Morg.,  hydatid 
of  Morgagni.     I'cd.  Ilyd.,  pedunculated  hydatid.     I'lff,  vagina;  Seasile  //i/J,  sessile  hydatid. 

)f  the  intestinal  mucosa  from  Ijlockinjj  of  tlie  crypts;  i)ancreatic  cysts 
(ranula  pancreatica) ;  cysts  of  the  mucous  jjlands  of  the  epiglottis,  the 
trachea,  of  f'owper's  jjlands,  and  the  glands  of  Bartholin;  hile  cysts  of 
the  liver;  cysts  of  the  kidney,  of  the  bladder  mucosa,  of  the  glands  of  the 
cervix  of  the  uterus  (ovula  Nabothi),  of  the  lacrimal  gland  (dacryops), 
of  the  ducts  of  the  mammary  gland  (galactocele) ;  wens  and  sel'iuemis 
cysts  of  the  skin.  Here  also  belong  cystic  dihitations  of  hollow  organs, 
such  as  the  gall-bladder  (hydrops  vesica  fellese),  of  the  appendi.x,  and 


CYSTS 


291 


tlir  r,.ll..,,iHn  t.iho  (hydrosalpinx);  tl.r  n-tn,tio.,  „f  ..toriia.  .iischarges 
In  (i< rhisKm  o\  the  cervix  jjives  hydrometra  " 

.-/'^'•''V'"/'"V'"  ^!"fr  ^'/'""/•^•- (JIa-xis  like  the  thyroid  and 
pitn,  ;.n  .  heinK  f«>rine,l  at  closed  vesicles,  are  liahle  t..  distensi,;,,  of  these 
MM.Io  so  that  thyroid  c.vsts  (thyroid  goitre)  or  pitnitarv  cvst.s  (K-cur; 
.„.!  11.  the  ovary,  ,.ysts  of  the  GraaHai.  follicles  «„d  cvstsof  the  corpora 
li.t.M  .,.;iy  arise  in  some  of  the  former  an  ovnm  may  persist,  thoiigh 
jr.hcniljy  It  undergoes  disinte);ration. 

III.  ( )K  Xkoi-lastic  OHKiix.-  1 .  Cystadenomas.-  Adenomas  of  tuh- 
nNirj:liMMis  In  tliecontinned  pro.lnction  of  (ahnormal)  secretion  become 
.li^t.i,, i...l  aiHl  <.ystic;  especially  is  this  true  in  the  ovary  and  the  mam- 
m,ry  i^liind;  and  in  snch  cysts  there  is  a  tendency  to  the  multiplication 

Fio.  143 


.nL',r,r!' ','  ?,"■'",", ''r  ^''^'r   '"""  "  "'■"'"'"'  •■''"''  '■■""«  "'"'■■'Iv  "f"  birth.    Each  orRan  Rrra.lv 

'-!Xx'"r::.,.!;r' u'"";,  r  ^''^^tl'^Pi'^'na^^''^  i">^rowths  of  great 

li.K  .  f  ,  ,r  iw         '"  '•''  "■'"'''•'■  '""'"Stood  that  here  the  horder- 

;        -  nr..  prnl.lerat.on   ,s  readily  passed  an.l   neoplastic  growth 

•^;/' •''  ■'  '.rciMoniatoiis  nature,  instituted.  fe™vMn. 

ol  the  lining  membrane)  is  a  relatively  small  one.     Tht 

,^^V'-M..>  .re  serous  cysts-sacs  .listended  with  serous  fluid  or 

;    .    •         ...c  sacs   are   normally  lined    by  endothelium,  either  of 

r  . on  ot  a  .serous  c-av.ty  or  of  the  lymphatic  system.     Ex- 

1 "         ..e  ioriner  are  scrotal  hydrocele  and  cysts  o«Lthe  cknal  of  Nuck 


292 


PROGRESSIVE  TISSUE  CHANGES 


',f  the  latter  buml  cysts,  ami  "fMiflta"  (rysts  fonncil  l.y  the  tuttinn-oir 

Bun^il  and  Ivmph  cy.ts  in  ge..eral  ..we  the.r  crigm  tc,  a  e..mh,nat...n 

of  c  cumstance';  there  is  iricreased  activity  and  lessene.1  ahsorp  u.„. 

and    n  manv  there  is  no  doubt  a  lew  Rrade  of  .nflajnnmt.on   whuh. 

Sling  to  a  progressive  thickening  of  the  .al!.  yet  further  interferes 

with  the  pn)i)er  degree  of  absorption. 

M  ero us  c Ists  of  congenital  origin  the  niost  stnku.g  are  the  hyromu. 

which  are  most  common  in  the  neck  (hygroma  co  h)  \et  l^e  »<yj  "  •« 
s  generallv  not  a  simple  cyst  hut  by  reason  ,»f  plent.fn  endothei.al 
eproduction  may  be  recognizinl  to  be  a  lymphangUM^ndothehoma. 


Fia.  144 


papillary  ingrowth*;  ^.  fibrous  stroma. 

3.  Ependymal  Cysts.-Imperfect  development,  or  intra-uterine^ii.flam- 
ma  ion  leading  to  stenosis,  may  cause  a  localized  closure  of  some  part 
S  the  spinal  or  cerebral  canal,  or  of  the  channels  o  communication 
between  S  canal  and  the  external  lymphatics.  Either  happening 
^'rS  to  accumulation  of  cerebrospinal  fluid  .md  cystic  dilatatim^ 
of  the  entricles  or  of  the  spina'  canal,  giving  nse  to  hydroceph^» 
LmL.  hydrocele  of  the  fourth  yentricle.  or  cysts  of  the  ^  ^^ 
^^h  as  s^gomyelocele  (to  be  distinginshed  from  cystic  state  he 
n  e  i4es)  A  snaring  of?  of  portions  of  the  ej^ndyma  duru.gde^.eUp- 
ment  may  lead  to  the  appearance  of  simple  cysts  m  the  gray  matter, 
thev  mav  be  lined  by  a  ciliated  epithelium.  .    ,•     i  k- 

4   Squamous  EpitheUal  Cysts.-As  already  noted,  the  cysts  hn^l  b 
squamous  epithelium  and  having  sebaceous  contents  may  sho.^     lem 
sXron  eit'hcr  side  of  the  neck,  as  the  outcome  of  Pe--^-- ^^^ 
outer  epithelial  portion  of  one  or  other  branchial  cleft.    A  fau  >  commo 


CYSTS 


293 


form  i)f  uc<iuiretl  epitheliul  cyst  is  met  witli  in  the  finders  of  sewing 
wdimii,  and,  more  rarely,  aa  the  result  of  other  forms  of  trauma.  As 
the  nsiilt  of  small  jxirtions  of  the  epiderm  becoming  driven  into  the 
iltr|Hr  tissues,  the  cells  persisting  grow  into  a  globular  niuss,  the  actively 
prolilVrating  cells  being  on  the  outside,  the  cell  debris  accumulating 
witliiii,  as  indicated  in  Fig.  14.5. 

Fia.   145 


2 


m 


I)i;ii.'r:ini  tti  ithiBtrutc  mode  of  formation  of  an  implantation  cyst  of  Hltin:  1  shows  a  fragment  of 
liliin  ilf'pii'^'ii'tl  into  tlie  underlying  tisaucs:  the  actively  growing  cells  of  that  fragment  are  upon  its 
iii'<U-r  :i:>|H'rt  Ht  a  (the  palifiade  layer  of  the  rete  Malpighii);  the  stratified  flattened  cells  of  the  epidermis 
i:it  t"  iKivf  l(»Nt  the  power  of  growth;  2  and  3  show  the  continued  growth  of  the  celts  of  the  rete  Malpighii, 
ulii'li  Iritiii  the  wutit  of  growth  of  the  <-ells  at  h  must  come  to  surround  those  cells,  and  form  as  at  4  a 
-cili.l.  MiKJ  lutir.  us  ut  3,  .1  hollow  sphere. 


.").  Composite  Cysts. — ^These  are  cysts  whose  walls  are  composed  of 
iiKirf  than  one  kind  of  epithelium,  whose  contents  are  from  glands 
ili")  hiir^in^  into  the  cyst;  sequestration  cysts  of  the  skin  are  such,  as 
i>  hydronephrosis. 

Sttiucstration  cysts  occur  in  the  line  of  fissures  of  the  body,  where  in 
the  process  of  joining,  some  cells  of  one  or  both  surfaces  become  de- 
prissitl,  and  sequestered  in  the  underlying  tissue,  there  eventually 
^'i\  inj;  rise  to  a  cyst.  This  may  occur  at  the  dorsal  groove,  the  thoracic- 
iilidoiihiial  cleft,  or  the  facial  clefts,  and  in  the  part  cut  off  there  are 
j;(  inriilly  sweat  or  sebaceous  glands,  and  hair  follicles,  which  determine 
the  iiiitiire  of  tiie  cyst  contents.  Such  cysts  may  not  only  be  superficial 
liiii  (itrp,  and  because  of  the  comparatively  late  development  of  the 
-kiiN,  t'lcy  may  be  found  attached  to  the  dura  mater.  Hydronephrosis 
("(ur>  when  the  urinarj-  passage  is  obstructed;  the  kidney  continues 
to  -(I  rite,  and  the  urinary  canal  to  be  distended,  especially  the  pelvis 
of  till  kiilncy,  so  that  ultimately  the  kidney  itself  may  be  transformed 
into  a  thill-wailed  sac.  Of  the  nature  of  composite  cysts,  too,  are  those 
ill  lii>ions  of  tooth  sacs  or  remains  of  the  enamel  germ  that  are  found 
iii  'iic  jaw.  These  may  be  lined  by  epithelium,  and  may  even  have 
til  til  ])r(ijecting  into  them,  in  which  case  thev  are  true  dentiferoos 
cyst". 

i  '•■  Hemorrhagic  Cysts. — In  the  brain,  as  a  good  example,  we  find 
f;  1  torination  following  upon  a  hemorrhage;  the  blood  outpoured 
;i' '  :i^  a  foreign  body  and  the  tissue  makes  an  attempt  to  wall  it  off 
'  tiiiniiis  capsule,  while  at  the  same  time  leukocytes  and  autolysis 
;ir    r.  .p,,iisil,|e  for  the  removal  of  the  corpuscles.    The  blood  pigment, 


291 


I'RmRKSaiVE  TISSUE  CllANaBS 


m 


t(M>,  in  (;ru«liially  removed,  so  ttint  ii  sninll  amount  tirouiui  the  capsi 
may  be  the  only  inchcation  of  the  faet  that  McmmI  has  been  pres«'i 
and  even  this  ultimately  disappears.  The  cyst  fiiuilly  contains  a  clei 
serous  fluid.     A  like  pr<K'«'ss  m-curs  in  the  goitrous  thyroid  and  in  t 


Km    UO 


Diagrutii  of  an  Eehinncocctis  hydatid:  ru,  thick  cxtcrual  cutiirle;  pa,  p^xrenchymal  (ft*>rmin 
layer;  t\  d,  r,  dcvclopnicnt  of  Ifie  heads  accordiiiK  to  Leiickart : /.  3,  h,  i,  k,  development  of  thi-  hci 
according  to  Moniei;  /,  fully  deV4'loiK'd  bnnjd  capsule  with  heailH;  m,  the  hroo<l  capsule  ha;t  luptup 
and  the  heads  hang  in  the  lutnen  of  the  hyilatiil;  u,  litxTiitcd  head  floating  in  the  hydatid;  ".  />.  4.  r 
tnodc  of  formation  of  wcondary  exogenous  dauKhler  c\st ;  /,  daUKlitcr  cyst,  with  one  cndoKcmtuB  a 
onu  exogenous  grund-<lauKht«*r  cy.st ;  u.  v.  x,  format  ion  of  cxoKeimuM  cy:*t  (iifter  Kuhn  and  I);ivain 
y,  z,  formation  of  endogenou.s  dauKhter  cystM  (after  N':oili\n  and  f^ouckart):  u<  at  the  exiwitse  ul 
head;  z,  from  a  broad  capsule;  rraij.,  constricted  p<irtion  of  the  mother  cyst.  (R.  Blanchard,  sligh 
modified.) 

scalp  of  the  newborn  (cophalhematoma) ,  and  sometimes  in  the  CDrpi 
hiteum,  although  the  metamorphosis  of  tlie  last-named  has,  of  t  (tiirs 
a  much  deeper  significance  liian  the  mere  formation  of  a  cyst. 

C.  Necrotic  Cysts. — \Vherever  there   has   been  a  necrosis  of  li>»i 
without  infection,  as  in  a  large  infarct,  it  may  happen  that,  after  tl 


mmmm 


CYSTS 


205 


ti>MH>  has  liecomo  li(jiH'fie<l  l»y  autolysis,  the  soluble  products  diffuse 
out.  the  lynipli  «liffuses  iti.  hikI  a  cyst  is  formwi.  Such  a  formation  may 
Id' »( 111  in  the  centre  of  a  large  cancerous  no«liile. 


Fio.  U7 


Nriruiio  ..jut  (.(  liver  due  to  occroMH  and  autolyaia  of  the  rrntral  region  of  a  •eeondary 
curcinoiiiatoui  nodule, 

i)  Paraaitic  Cysts.— Certain  metazoan  parasites  pass  one  cycle 
"I  their  ixisti'iice  in  a  cyst  within  the  tissues  of  their  host.  Those 
•itriirriii);  most  notably  in  man  are  Tcenia  echinococcus  and  Trichina 
^I'lrnlis,  the  cysts  of  the  latter  being  very  small,  containing  each  a 
j'"l<.l-p',  individual  trichina.  The  cysts  made  by  the  former  are, 
It'iwt  \.  ,  of  large  size,  and  wcur  most  often  in  the  liver,  although  many 
"th.  r  organs  may  be  foiuid  to  contain  them.  The  wall  of  the  large 
•  >>i  i>  Mii)i)lied,  in  part,  by  the  parasite,  althoi-  jh  the  irritation  of  its 
pr.M  IK  I'  leads  the  surrounding  tisRiio  to  build  a  nbrous  capsule  on  the 
|"itM(lf  of  the  hyaline  cyst  wall  proper. 

'I'lii>  .-(.-called  hydatid  cyst  may  be  single  or  multiple;  its  wall  is  hva- 
li'"  inil  larniiii.l'MJ,  lined  internally  by  a  granular  (cellular)  '-^yer  from 
«li:!i  project  t.ie  iieads  of  new  individual  parasites,  with  character- 
i-ii(  liotklet  Secondary  heads  ar-  constantly  being  buddeii  off 
rmii  the  vvall  :.,id  thrown  into  the  fluid;  these  it  is  which  render  the 
"in.l  likely  t  .  infect  the  peritoneum  if  allowed  to  come  in  contact 
"itl,  It  .lur.!  ,  remt.vid.  The  secondary  heads  mav  give  rise  to  the 
"H,  at  toil  ot  daughter  cysts  in  the  primary  sac,  or  less  frequentiv, 
til'  'liiUL'liter  cysts  may  form  on  the  outside  of  the  mother  cvst  in-^-ad 


•  iiiMile,  causing  a  multilocular  cyst. 


:i:    I 


CHAPTER    V 

THE  REGRESSIVE  TISSUE  CHANGES 
NORMAL  HISTOLYSIS  AND  CTTOLTSIS 

For  a  proper  understanding  of  the  regressive  tissue  changes,  it  is 
necessary  to  consider  how  the  tissues  naturally  decay,  for  however 
rarely  we  pay  attention  to  this  phenomenon,  it  is  going  on  constantly. 
Tissues  and  organs  in  the  embryo,  representing  ancestral  structures, 
appear  and  disappear.  The  thymus  reaches  its  maximum  during  the 
first  two  years  of  life,  and  undergoes  absorption;  the  lymph  nwles,  at 
their  largest  in  youth,  become  smaller;  the  milk-teeth  disappear  before 
the  inroad  of  the  permanent  set;  after  pregnancy  the  uterine  tissue 
undergoes  involution,  that  is,  the  cells  which  were  hypertrophied, 
atrophy ;  the  ovaries  atrophy  at  the  menopause.  Red  blood  corpuscles 
and  leukocytes  have  a  life  of  but  a  few  weeks;  they  disintegrate  and 
are  eaten  up  by  other  cells;  even  so  solid  a  structure  as  bone  is  under- 
going constant  change.  All  this  is  but  the  analysis  of  the  popular 
saying  that  the  tissues  are  renewed  every  seven  years;  the  particular 
definite  length  of  time  has  no  foundation,  but  the  principle  is  true. 

The  destruction  of  cells  in  the  ordinary  wear  and  tear  of  tissues  is 
doubtless  a  complex  process,  the  result  being  due  to  changes  in  the  cell 
itself,  as  well  as  to  forces  acting  outside  the  moribund  cell.  We  are  not 
in  a  positixjn  to  recogni/A'  the  signs  of  approaching  cell  death  by  any 
special  histological  change,  but  we  can  tell  sometimes  that  cells  are 
growing  old;  in  senile  atrophy,  for  instance,  the  cells  grow  smaller  and 
often  lose  finer  details  of  structure,  such  as  the  transverse  striations  of 
muscle  fibres.  A  cell  in  this  state  of  senility  is  not  as  capable  as  it  once 
was  of  carrying  out  its  functional  duties,  and  sulistances  which  it 
ab'^orbs  are  not  properly  or  completely  converted  and  tend  to  be 
stored  up;  the  products  of  its  own  cell  disintegration,  if  not  solul)le,  in  a 
similar  way  tend  to  be  stored  up,  so  that  by  the  presence  of  paraplasmic 
material  in  the  cell  we  may  recognize  its  senility,  either  natural  or  pre- 
mature. An  excellent  example  of  this  is  seen  in  the  so-called  brown 
atrophy  of  the  heart  muscle  cell,  in  which  the  cell  is  seen  to  be  smaller 
than  normal  and  to  have  at  each  pole  of  the  nucleus  a  deposit  of  fine 
reddish-brown  granules,  which  are  thought  to  be  the  final  insoluble  [nod- 
uct  of  the  breaking  down  of  myohemoglobin.     (See  Plate  VII,  Fig.  1) 

Ecjually  good  as  an  illustration  is  the  change  wrought  in  the  muscle 
of  the  uterus  after  i)arturition.  During  pregnancy  the  muscle  fibres 
have  undergone  i-'inu-nse  hypertrophy,  and  during  the  first  w«'rk  after 
delivery  they  shrink  in  a  degree  no  less  remarkable;  from  I   ing  un  an 


.^ite 


..:'..  J  nam 


WW 


PLATE  VII 


Brcivvn    Ali'iipliv. 

lli..^M,    -,lr..,.hv    ..I     I,,... lit.    Ii...,i    -.,-,   iM.n    -Kiin...i     l,v    Kil..x>lin.     1.,    -I,,.w 

''•■■"'"'""'■'' '      ■••■l.h-h- 1  ,i(  ,^\  II      |, I, nil, Mil     ,|l;iiiiil.--.     .It     ..|lli.-i      |„,l,.     ,,r 

•■■•    I'!    "I    111.-    nM'ii|.liM      mil-.    I.-    hill-,.- 


Fiiilv    DefifMUMiiIlc  >n. 

'ii'i-.'-    ,,r     li,.;iri     rr,,iii     ,.,,„.     ,,|     |„.rui.-i.iu-.     ;iii..iniM,     -,u,iiiM,l     l,\ 
I     "I'l    h. -111,11, ,x^  1,1,    .,,   -!,,,„     liui\    <l.-,|.-n<-r:ilic,ii    111  v.ilvin.i   ,ii,,iiii~ 

I  .    L ■  ->       .  1 


'a 


^Ita 


^25^E^ri»71?SE^SS^S 


ATROPHY 


297 


a\  truije  20S  li  long,  they  become  reduced  to  24  m-  (Sanger.)  In  addition, 
tluy  look  more  cloudy,  and  sometimes  show  refractile  globules  of  fat. 
'Ihis  is  fatty  degeneration,  and  a  simultaneous  fatty  infiltration  is 
\  i^ihli-  l)et\vcen  the  deeper  muscle  cells,  this  fat  disappearing  with  con- 
>i(l(r:il)k'  rai)i<lity.  We  have  in  this  example  cloudy  and  fatty  degen- 
tnitioii  and  fatty  infiltration  all  occurring  in  a  process  which  we  regard 
:i^  iKinnal. 

'i'lu'  factors  which  are  most  potent  in  determining  the  state  of  a  cell 
arc  nutrition  and  the  performance  of  function;  if  nutrition  be  good  and 
tlitrt'  he  loss  of  function,  atrophy  will  supervene  from  disuse;  if  there 
l)e  txcessive  function  with  normal  nutrition,  there  will  also  be  atrophy. 

Causes  of  Atrophy. — Briefly,  we  find  various  orders  of  atrophy: 
(Ij  disuse  atrophy;  (2)  atrophy  due  to  excessive  function;  and  (3) 
atri)i)liy  due  to  lack  of  nourishment. 

! .  Disuse  Atrophy. — The  enforced  rest  of  muscular  tissue  brings 
alidiit  true  atrophy,  that  is  not  necessarily  a  reduction  in  the  numbers 
<il  tlic  cells  but  a  re<luction  in  the  size  of  the  individual  cell;  this  will 
rt  >ult  from  tiie  inunobilization  of  a  limb  by  mechanical  means,  or  if  the 
IK  r\t'  1)1"  severed.  Disuse  atrophy  is  very  well  shown  in  the  nervous 
systiin,  ill  which  it  was  for  long  thought  that  when  an  axone  was  severed, 
a  (It'jrciu'ration  only  in  the  distal  severed  part  occurred;  but  there  is 
MKiri'  tliaii  this,  for  a  disuse  change  occurs  even  in  the  nerve  cell  body, 
ami  tliis  is  especially  so  in  areas  where,  in  health,  there  is  a  constant 
HKccssioii  of  stimuli  reaching  the  cell;  in  the  absence  of  these  stimuli 
there  is  atrophy. 

L'.  Atrophy  from  Overwork.— Overwork,  carried  beyond  a  given  limit, 
t(  ,i(ls  til  induce  cell-exhaustion,  if  continued,  to  produce  cell  atrophy. 
it  is  difficult  to  bring  forward  clear  examples,  but  we  would  suggest 
that  certain  of  the  professional  palsies  belong  to  this  category. 

;;.  Atrophy  from  Malnutrition. — The  alteration  of  the  body  from 
general  starvation  is  a  case  in  point,  as  well  as  the  atrophy  of  special 
areas  whose  arterial  supply  is  pressed  upon  and  lessene(l;  even  the 
airupliy  causeil  by  pressure  is  another  example  of  the  same,  the  most 
ih  ii-c  tissues,  like  bone,  tnidergoing  atrophy  when  subjected  to  constant 
lire-^nre  even  by  a  fluid  mass. 

Senile  Atrophy.  A  closely-allied  form  is  senile  atrophy — the  natural 
>i;irini;  out  of  the  tissues;  but  there  is  another  factor  concerned,  for 
!'i  -oiiic  ])copic  tiie  process  begins  at  an  earlier  period  than  in  others. 
>iime  tissues,  too,  grow  old  more  quickly  than  others,  and  as  a  general 
I  nh  tiic  first  to  atrophy  are  those  that  become  functionless  during  the 
I  itiirai  lifi':  next  to  tl  .-se  come  the  lymphoid  structures— lymph  nodes, 
Maliiitrliiaii  liodies  .it  the  spleen,  and  the  red  bone-marrow — which 
iiilerp)  ^rptat  diin'.nution;  next  to  these  come  "store-house"  tissues, 

■  h  as  the  fatty  tissue.  Nervous  tissue,  ordinarilv,  shows  atrophy 
'    it  of  ail. 

\\^--n)  fatty  tissue  atrophica,  tlic  fat  gradually  melts  away  until  the 
'    !ia-  once  more   become  a  connective-tissue  cell,  but  sometimes 


^i^^KT«<>^^^.ar-<  Y*'>M*EfiHV ' 


;'(^-i^^'-6*:;i..:;W" 


^^s^^Kr^r^^^Tv^ 


298 


THE  REGRESSIVE  TISSUE  CflAXGES 


m 


instead  of  this  the  phice  of  the  fat  is  taken  by  a  serous  fluid,  so  thai 
H  large  mass  of  fatty  tissue  so  altered  apjjears  translueent  and  jelly- 
like. This  so-calle(i  serous  atrophy  of  fat  is  not  definitely  known  t( 
be  a  purely  senile  ehanRe,  but  may  be  so  regarded.  When  the  cells  ol 
the  active  tissues  atrophy,  we  have  first  the  diniiiuition  in  size,  tnit 
atrophy,  then  in  more  extreme  stages  a  diminution  in  number  (hypo- 
plasia), and  along  with  this  the  dejjosit  of  pigment,  especially  in  those 
cells  that  normally  contain  pigment.  This  pigmentation  occurs  in 
brown  atrophy  of  the  heart,  as  we  have  already  iiulicated,  and  it  happens 
similarly  to  a  marked  degree  in  the  liver. 

In  bone  the  process  of  atrophy  is  a  rarefaction  whereby  there  is  an 
actual  loss  of  bony  substance,  the  individual  bones  become  lighter,  and 
there  is  an  increasecl  liability  to  fracture.  The  loss  of  substance  is 
largely  central,  the  medullary  c-vity  and  the  Haversian  canals  being 
increased  in  size,  and  the  tral)ecuhe  .-.iid  lamella'  thinned;  the  red  cellular 
marrow  becomes  replace*!  by  fat,  which  again  may  undergo  the  before- 
mentioned  serous  change. 

The  characteristic  changes  in  the  senile  skin  are  due  not  so  much  to 
any  epidermal  changes  as  to  a  loss  of  subcutaneous  fat  and  fluid,  accom- 
panied, of  course,  by  actual  tissue  shrinkage;  the  elastic  tissue  of  the 
dermis  is  also  altered,  bet  oming  less  resilient.    This  elastic  tissue  change 
becomes  very  important  in  the  senile  degenerations  that  occur  in  the 
arteries  and  the  lungs.    In  the  arteries,  as  the  walls  lose  their  resilience, 
the  arterial  tube  dilates  and  is  unable  tf)  recover  itself,  remaining  per- 
manently e.xpaixled.   At  this  stage,  when  the  expansion  is  permanent,  we 
may  find  so  difl'use  an  enlargement  as  to  constitute  a  fusiform  aneurysm, 
or  if  localize<l,  a  saccular  aneurysm,  although  these  rarely  if  ever  arise 
from  senility  alone.    In  either  case,  the  wall  is  found  to  be  thinned 
and  atrophied,  and  some  layers,  especially  in  the  muscle,  may  disappear. 
The  increased  caliber  of  the  vessels  causes  a  slowing  of  the  blood  stream 
and  the  consequences  of  the  same  in  the  tissues  supplied.    But  along 
w  ith  this  atrophy  of  the  wall  proper,  we  have  a  series  of  important  com- 
pensatory changes;  as  the  arterial  wall  gives  way,  there  is  a  connective- 
tissue  overgrowth  in  the  intima,  as  a  result  of  which  the  lumen  is 
restored;  this  process  is  arteriosclerosis.     Although  the  compensation 
may  be  in  bulk  equivalent  to  the  tissue  lost,  and  may  ultimately  come 
to  contain  eht  .lie  fibrils,  yet  the  wall  has  lost  in  elasticity,  so  that  the 
pulse  waves  are  conveyed  with  greater  force,  or  at  least  with  less  mwli- 
fication,  into  the  arterioles,  which  in  turn  undergo  a  similar  change  to 
the  detriment  of  the  tissues  supplied.    A  like  loss  of  elasticity  in  the 
tissue  of  the  lung  gives  origin  to  emphysema— dilatation  of  the  air  sacs; 
with  the  lung  tissue  in   this   relatively   non-eiastic   state,  suddenly 
increased  intrapulmonary  pressure,  such  as  occurs  the  moment  before 
a  cough  "explodes,"  tends  to  rupture  the  weaker  interalveolar  walls, 
so  that  several  alveoli  are  thrown  into  one,  and  the  distension  thus 
j)r(><hjced,  which  ordinarily  is  rectifietl  by  the  elasticity  of  the  lung 
tissue,  remains  permanently.    When  the  alveoli  are  thus  distended,  the 


.«rvxK^35rV»^%'' 


iWi 


ABIOTROPHY— KATAPLASl  A 


299 


rii|)illaries  in  the  walls  are  pressed  upon,  and  flattened,  and  a  greater 
iiiiiount  of  work  than  normal  is  thrown  upon  the  right  ventricle.  C'oin- 
( iilciit  with  the  distension  of  the  alveoli,  there  is  a  deposit  of  eonnective 
tis>iic  around  the  arteries  and  bronchi. 

Throughout  the  tissues  of  the  body,  with  the  exception  of  the  nervous 
s\  stem,  there  is  everywhere  to  be  seen,  along  with  the  senile  atrophy  of 
tiic  specific  tissues,  this  relative  increase  of  the  lower,  supportive  tissues. 
This  is  partly  relative,  that  is,  as  the  other  tissues  abate,  the  fibrous 
tissue  conies  into  greater  prominence;  l)ut  more  than  this,  there  is  actual 
incnase.  a  replacement  fibrosis;  and  this  is  more  pronounced  in  the 
li.ri\ascular  (periarterial)  regions  than  elsewhere.  The  nervous  system 
wiis  stated  al)ove  to  be  an  exception;  here,  it  is  true,  there  is  peri- 
iirtcrial  increase,  but  there  is  relatively  little  or  no  gliosis;  the  place  of 
lost  substance  is  filled  not  by  tissue,  l)ut  by  fluid,  a  hydrops  ex  vacuo, 
which  is  the  reason  for  the  oedema  of  the  pia  so  often  observed  at  autopsy 
in  those  far  advanced  in  life. 

Abiotrophy.— A  condition  allied  to  senile  atrophy,  called  by  Gowers 
alm.trophy,  -equires  mention.  There  are  certain  "familial  paraplegias, 
diseases  like  i  iiomsen's  disease,  and  the  so-called  parasyphilitic  diseases 
tliat  lack  explanation,  as  well  as  paralyses  developing  in  the  most 
exercised  limbs.  Certain  cells  and  systems  of  cells  degenerate,  and 
ultimately  become  disorganized,  the  rest  of  the  system  remaining 
uiiphaiiged,  and  this  often  in  a  way  that  suggests  that  the  trouble  is 
(■(jiin.ctcd  with  heredity.  The  conception  of  abiotrophy  is  that  these 
ctHs  begin  life  with  less  resistance,  with  less  potential  energy  than  others, 
s(>  tliat  tile  stress  of  a  toxin,  such  as  that  of  syphilis,  uses  up  a  consider- 
ahlc  i)art  of  their  energy;  later  on,  they  quickly  become  exhausted  under 
ii  stress  that  is  no  greater  than  normal,  even  although  this  stress  be 
no  (itlier  than  the  usual  work  that  is  demanded  of  such  cells.  An 
i\|)(riiiient  that  exemplifies  such  a  general  abiotrophy  is  to  expose 
fro-  --pcnnatozoa  to  the  .r-rays;  the  ova  are  fertilized,  but  the  larvie, 
atiir  a  few  days'  growth,  expire  prematurely,  cell-exhaustion  having 
sniHTveiied. 

Reversionary  Metamorphosis;  Kataplasia.— While  studying  atrophic 
•liiiniris,  It  is  necessary  to  mention  a  regressive  process  that  mav  some- 
tinus  I,,,  found  accompanying  them.  In  this,  highly  organized  cells  are 
stcn  t()  (liange  to  a  less  specialized  state,  to  become  more  embryonic, 
a  Kindition  of  aftairs  that  has  been  well  observed  in  muscle  fibres;  just 
ii-  tlic  sarcoblast  by  slow  transition  becomes  the  muscle  cell  in  a'pro- 
^n.MN  (■  way,  so  the  muscle  cell  may  become  the  sarcoblast  in  a  regressive 
]'■■'>}  The  most  commfnily  seen  example  of  the  process  is  i-i  the  liver 
'II  "  lii.h  the  bile-duct  cell  and  the  liver  cells  have  a  comjion  origin,  and 
■1  t'i  'iilar  arrangement  of  cells  is  the  earliest  grouping  that  is  seen;  in 
thr .  t\,l„p,„j,  liver  there  is  a  time  during  which  the  liver  cell  and  the 
[II.  -'Inct  cell  are  not  to  be  recogni.  id  one  from  the  other.  Wh^n,  as 
in  cirrhosis  of  tli.   ''         *>  >  'iver  cells  ber:i  to  atrophv,  the 


trail  ifion  from  liver  cells  ti 


cells  become.  ,  <adual,  and  cells 


I- 


300 


THE  REORESSIVE  TI  SUE  CHANGES 


,'i 


or  groups  of  cells  isolated  by  the  comu-ctive  tissm-  at  the  edge  of  a  lobule 
are  of  an  intermediate  type,  smaller  than  liver  cells  and  larger  than 
bile-<luct  cells,  in  fact,  a  reversion  to  the  period  in  which  the  two  were 
not  differentiated.  These  groups  of  cells  are  often  called  proliferated 
bile  ducts,  but  they  are  not  true  bi.c  ducts  by  reason  of  the  imperfect 
arrangement  oi  the  cells.  In  this  very  instance,  it  must  be  kept  in 
mind  that  the  process  just  describetl  may  well  be  associated  with  the 
opposite  process,  that  of  a  compensatory  hypertrophy,  the  still  per- 
sistent bile  Jucts,  as  the  lower  type,  proliferating  to  supply  the  lack  o 
liver  cells,  and  it  may  be  quite  impossible  to  say  whether  an  individual 
intermediate  cell  is  in  progression  or  regression. 


Fio,  148 


Revcrrionary  atrophy  from  .  case  of  fibrods  of  the  lunr  the  alveoli  shrunken  by  the  growth  of 
the  ™n,^g  connective  ti«ue  have  become  lined  by  a  cubical  ep.theUum.  reaemblmg  that  «=en 
in  the  lung  of  the  fcetua. 

Another  oft-seen  example,  is  the  assumption  of  a  cubical  shape  by 
the  cells  lining  lung  alveoli  in  compression  of  the  lung  or  interstitial 
fibrosis,  which  is  a  reversion  to  the  type  of  cell  seen  in  this  situation 
before  pulmonarv  respiration  began ;  similarly  in  the  kidney,  in  nephritis, 
the  epithelium  of  tubules  and  of  glomeruli  may  be  seen  to  take  on  the 
embryonic  cuboidal  shape. 


THE  DEGENERATIONS  AND  INFILTRATIONS 

Even  in  simple  atrophy  we  are  dealing  with  more  than  a  mere  pro- 
gressive reduction  in  the  volume  of  the  cell-constituents  for  we  Iia%e 
Iho  certain  changes  in  the  nature  of  the  cjtoplasrn  itself.  This  ye  > 
heaoing-np  of  what  we  term  by-pro.lucts  must  tell  deleteriouslj  upon 
the  cell  and  its  activities.  It  was  thought,  but  now  seems  less  ctrr.a  n, 
that  we  could  distinguish  two  processes,  which  might  accompany  ea.n 


CLOUDY  SWELLING 


301 


(itluT,  one  the  chaiiKf  wrought  in  the  cytoplasm  itself  leading  to  the 
iil)|)carance  in  the  ceil  of  such  changed  products,  and  the  other  charac- 
tcri/t'd  by  the  appearance  in  the  cytoplasm  of  substances  obtained  from 
iiiitsidc  the  cell,  and,  it  may  be,  imperfectly  handled  by  the  cell.  It 
was  thought  that  the  former  were  degenerations  proper  and  the  latter 
infiltrations,  but  further  study  shows  that  it  is  becoming  increasingly 
(iitficiilt  to  separate  the  two,  that,  in  fact,  they  are  too  closely  related  to 
jHTinit  of  being  considered  apart.  Kspet-ially  does  it  seem  to  be  that 
triH"  infiltration,  by  itself,  is  a  rare  occurrence.  Cells,  it  is  true,  become 
infiltrated  with  or  contain  the  substances  in  question,  such  as  fat  or 
^'l>(uf;fn,  but  it  is  doubtful  if  this  is  secjuent  to  a  process  of  absorption 
of  the  fat  or  glycogen  as  such;  it  is  more  likely  that  these  materials 
art"  the  result  of  synthetic  processes,  the  activities  of  the  cytoplasm 
Ix'ing  responsible  for  their  appearance.  For  example,  fat  as  such  is 
IK  it  to  be  detected  in  the  blood,  for  it  is  to  a  great  extent  saponified 
hfturc  its  absorption  by  the  intestinal  mucosa,  where  it  is  converted 
into  a  soluble  compound.  This  the  liver  absorbs  from  the  blood, 
ail' I  reconverts,  by  its  ferment  activity,  into  fat.  When  globules  of 
tat  appear  in  the  diseased  cell,  it  is  not  likely  that  these  arise  from 
tiic  lireaking  down  of  the  protein  of  the  cytoplasm,  but  rather  they 
ajiiKar,  perhaps  in  excess,  as  a  sign  of  the  lack  of  competency  to  deal 
witli  them  on  the  part  of  the  cytoplasm.  Whatever  be  the  source  of 
tlioc  ])araplasmic  substances,  de^'eneration  and  infiltration  are  so  closely 
linked  that  they  may  well  be  considered  together;  in  many  cases,  in  fact, 
thf.\  are  inseparable. 

Cloudy  Swelling. — Perhaps  the  most  common  morbid  change  seen 
at  autopsy  is  that  of  cloudy  s^\elling  or  albuminous  degeneration,  in 
wliidi  the  cut  surface  of  the  organ  has  a  dulled  appearance,  as  if,  to 
tiiijiliiy  a  much-used  phrase,  it  had  been  momentarily  dipped  in  boiling 
\vat(  r.  With  this,  there  is  d  certain  amount  of  swelling,  which,  in  the 
ividticx ,  causes  the  cortex  to  rise  above  the  level  of  the  medulla  and 
makes  the  cut  edge  to  evert.  The  individual  cells  have  lost  transpar- 
tiu  \ ,  anil  an  unstained  section  will  show,  by  transmitted  light,  the  cells 
(ir  urmips  of  cells  that  are  cloudily  svsollen  as  shaded  with  gray,  con- 
trasting' with  the  clear  white  of  normal  tis.sues.  On  close  inspection,  the 
mil  1(  i  look  as  if  obscured  by  the  deposit  of  a  finely  granular  material  in 
the  (yti)])lasm,  and  they  stain  less  readily  than  usual.  Weak  acid  or 
weak  alkali  clears  up  this  cloudiness,  apparently  by  dissolving  out  the 
prei  ipitated  proteid  or  albuminous  material. 

<  liiii.ly  swelling  is  found  in  the  cell  under  many  different  conditions, 
iliiet  111  which  are  acute  infections  and  high  fevers;  it  is  seen  also  in 
varimi-  intoxications,  after  chemical  poisons,  in  burns,  and  even  in 
star,  uidii;  the  granular  material  which  appears  is  evidently  a  product 
lit'  ah.  red  cytoplasm,  and  seems  like  the  granular  material  ordinarily 
iks(  ri'iieil  as  Altmann's  granules,  but  with  this  distinction,  that  it  seems 
aRi.T.  .licii  into  larger  masses,  and  there  is  none  of  the  regular  linear 
arraiL  rnent  seen  in  the  normal.    It  is  not  possible  to  say  definitely 


,j.'*r^.,|,„*iiF^-. 


302  THE  REdliESSIVE  TISSIE  (H.WdES 

what  this  matcTial  is;  accnliuK  t..  Martin  Fischer,  it  is  to  be  reKardecl 

as  the  result  of  conversion  of  certain  coHohIs  of  the  cytoplasm  from  the 

soluble  int..  the  soli.l  or  "^el"  state.     It  is  evi.lently  either  material 

(lisintenratcl  fn.m  the  cytoplasm  or  material  absorbed  an.    not  com- 

nk-telv  ••  han.lle.l"  bv  the  cell ;  ..r  finally,  it  may  be  b..th.     The  increase 

in  si/.;-  is  partlv  .lue  to  the  increase  in  these  paraplasniic  materials,  but 

mainiv  t..  a  hv.ln.pic  oiulition  aiul  increase  in  the  watery  constituents. 

(■l.ui.lv  swelliiiK  is  n..t  t..  be  c.nf.uin.le.l  with  granular  .lefieiierati..!., 

which  is  a  .lisintegrated  state  ..f  pr..t..plasm.  an.l  a  precurs..r  of  cell 

death-  the  .In.plets.  at  least  the  larger  ..f  them,  are  .lue  t.)  hquefactive 

necrosis.    The  process  <.f  cloii.ly  swelling  thus  seems  t..  be  the  expre«si..n 

„f  overstimulati..n  of  the  cell,  with  .lisonlered  metab..lism  an.l  the 

heaning-up  of  paraplasmlc  matter  of  an  albuminous  nature;  apparently 

it  is  n.^  a  ncc.>sarv  cause  ..f  cell  .leath,  is  frequcPl  y  recovere.1  from, 

and  yet  is  pn.bably  the  earliest  stage  in  what  may  be  the  progressive 

deteriorati.m  of  the  sick  cell. 


Fia    149 


Kio.   150 


Clou.ly  awpllinRot  ii'llsof  coiivol-.ite<l  tiibuk-s  of 
kidmy.      X  400.     at'bbert.) 


I.iver   ccll»  in   vurious  stages  of  f.iliy 
iiccuiuuliilion.    X  300.    (Kindfleisch  ) 


1<A 


INTRACELLULAR  FAT  ACCUMULATIONS 

As  was  sai.l  abov.-,  two  states  are  to  be  considered-fatty  ^f^^ 
an.l  fattv  .legenerati..n;  pron..unce.l  examples  ..f  the  two  are  rea.l.l> 
distinguishable,  but  in  many  cases  the  two  seem  t..  be  blemie.1 

"Fatty  Infiltration."-Neutral  fat  is  a  c..nstituent  of  m.«t  of  the 
tissues  of  the  body,  but  in  a  state  unrcc.gnizable  ^-^1^";'^^ ^^^^^ 
chemical  means.  The  ki.lnex-  tissue  ma>-  be  dem.>nstrated  tc^  possess 
I;;"  the  extent  of  Z^  per  cent,  of  its  s.>lids,  yet  may  by  «tammg  -- 
tions  show  n.)  trace.  On  the  other  hand,  certain  regions  such  as  he 
subcutancus  c.nncctive  tissue,  the  omentum  the  appendices  p 
phnca.,  the  car.liac  gr.,.>v..s,  an.l  the  area  armni.1  th^k«!"^>.  "'^  jj'^ 
c.,ntain  fat  in  large  amount,  the  cells  being  distended  -  f^  i.  /J' ;; 
not  fattv  infiltrati.,..;  that  term  shoul.l  be  onfine.!  *»  ;»f' "^''^^/J", 
lective  tissue  elsewhere,  especially  in  the  interstices  of  tissues,  ^^h.ch 


xmvB^  m7H3"'™)wvB«!»'-"'*'w»'^:/T,'iaj 


ISTRACKUAJLAR  FAT  ACCUMULATIOSS 


303 


1„. „.s  thus  laden.    Tnu-  fatty  infiltration  may  thus  occur  lietwecn  the 

,  inliiic  nuiscle  fibres,  in  skeletal  nuis<-les,  or  in  an  orfjnn  like  the  pan- 
,  rri>  The  liver  cells,  too,  may  become  the  seat  of  a  notable  fat-fleposit, 
|„r(\ample,  during  pregnancy,  and  this  is  perfectly  properly  spoken 
„f  MS  fatty  infiltration,  it  niav  be  very  extreme  ni  such  states  as  chronic 
„l('oholism,  where  four-fifths  of  the  total  solids  and  41  per  cent,  of  the 
,rll  Mibstance  (including  water)  in  a  given  case  have  proved  to  be  fat. 
It  i.  to  i)e  remembered  that  in  aU  other  parts  of  the  body  fatty  mhltration 
atlVcts  the  connective  tissue;  in  the  Uver,  the  ci)iuiective-tissue  cells  are 
ii„t  involved,  but  the  liver  cells  proper. 
liitty  infiltration  may  thus  arise  from  a  number  of  causes: 
1  Physiological.— There  may  be  a  heaping  up  of  fat  in  the  liver 
.liirins;  pregnancy  aiul  lactation  apparently  as  a  preparation  for  the 

'  ■>.  Ovemutritioii.— The  "foie  gras"  of  the  overfed  Strassburg  goose  is 

a  fiiiniliar  example  of  this.  .    ,      .  ,1 

:;  Substitution.— Fatty  infiltration,  and  not  cirrhosis,  as  pop  larly 
MipiMHfd,  is  the  most  common  affection  of  the  liver  in  alcoholic-,  not- 
witliMiiiiding  the  fact  that  the  confirmed  alcoholic  is  not  a  heavy  eater; 
al((ai.,l,  being  a  foodstuff  capable  of  easy  oxidation,  probably  rej)laces 
tlic  fats,  and  these,  nt>t  being  oxidized,  remain  and  accunuilate  in  the 

'  '1.  Diminished  Oxidation.-  («)  Congenital.— There  are  some  people 
iiaiiirallv  obese  just  as  tl'.ere  are  others  naturally  spare.  The  former 
lurlnrn." tlK-ir  metabolism  slowly,  and  the  defective  oxidation  of  their 
tatt\  acids  leads  to  a  gradual  accumulation  of  neutral  fats  in  the  cells. 
Tli>'n,i(l  extract  lessens  obesity  in  such  people,  probably  by  reason  of 
it^arirlcrating  the  oxidative  processes. 

>/,  ThmiKih  Dlitease.—Vatty  infiltration,  of  the  liver  often,  and  of 
til.  .itlur  tissues  sometimes,  occurs  in  those  ill  of  a  wasting  disease 
(iiotr,!  ill  tuberculous  cattle),  because  lowered  vitality  and  low  func- 
tiduu!  activitv  of  the  tissues  mean  lessened  l)urning-up  of  the  fats  taken 
a^  1u,m1,  while  fat  from  the  subcutaneous  and  other  tissues  may  be 
trail  iMisfd  to  the  liver. 

"Fatty  Degeneration."— In  the  cases  of   fatty  degeneration  that 
apprir  to  be  trulv  such,  there  is  primarily  a  cell  degeneration,  the  fat 
:  (i.posited  as  a  result  of  depressed  cell  activities.    The  nuclei  may 
liooriv,  and  in  the  cytoplasm  are  minute,  dust-like  fatty  bodies 
-^tained  with  Sudan  III  or  Scharlach  R,  give  to  the  cell  a  diffuse 
-red  color,  the  hisrh  power  showing  that  this  is  due  to  abundant 
.'  t'att  V  dots.    The  tissues  so  affected  are:  (1)  those  liable  to  cloudy 
!!'.:  (gliiiid  cells,  especially  of  the  liver  and  kidney  (see  Plate  VIII, 
.  and  muscle  fibres,  especially  of  the  heart)  (see  Plate  VII,  Fig.  2) ; 
i,  lutliclial  cells  of  blood  vessels,  and  (3)  certain  cells  undergoing 
'■  rc;;rcssive  changes  (cells  of  the  sebaceous  glands,  of  the  mam- 


Iv 

■■t;ii; 
will-'- 
cr.'ii' 
mil.: 

Fi.. 


liii 
tii; 


V\ 


at  first  sight  appears  to  be  a  like  accumulation  of  fat  in  the  form 


■m: 


Via.  151 


304  THK  RKdRKSSIVE  TISSUE  CIIASGES 

of  minute   ulc.l.iiU-s.   I.tit   without  any   nu<l.-ar  <leK«'>»;ratinM.   occurs 

,wrmall„  iu  ti.c  cortex  of  thea.lreual.  an.l  ui  ti.emusclecellsot  t he  uterus 

undcrjioiuK  involuti..n  after  parturitiou.    (  )m  the  contrarv.  vvuh  nuclear 

'^      ^  dejjeneratioii  tlitre  may  Lc  Uir>,'e 

globules  of  fat  in  the  ceil,  as 
happens  in  phosphorus  poi^m- 
ing.  Histoh»Kieally,  it  is  there- 
fore not  saf»-  to  say  that  the 
minute  gh'hules  indicate  a  de- 
jjeneration  aiul  the  larger  ones 
an  infiltration;  there  are  evi- 
dently intermediate  states. 

Typical  cases  of  fatty  degenera- 
tion can  be  divided  inco:  (1)  those 

Fio.  153 


Section  showing  fntly  <lcgenerati<)n  of  the  opi- 
Ihcliura  of  the  renal  tuhiilca.  The  fine  fatty 
globules  are  accumulttteil  in  the  main  toward  the 
outer  aspect  of  the  cells,  close  to  the  basement 
membrane, 

Fio.  152 


*•>.'. . 


&ff 


m 


^ 


% 


Fntty  .legeneration  of  liver  cells:  h,  fresh  cells. 
cl.)U(lvaml  gr.inuliir,  nuilei  not  clear;  a,  the  fine, 
fatty  globules  seen  more  clearly  after  treatment 
with  acetic  acid.     (Uibbert.) 


Fatly  degencrali.  .  of  hci.rt-niusrlo  fibrcK. 
showing  diffrnutvr-"lesuf  involvement  of  iIk 
individual  fibres;  fti»h  specimen.     (Ribberl.) 


following  cloudy  swelling,  therefore  the  second  stage  '"f /^"/''Y*^;  "" 
inflammation  of  organs,  and  (2)  sm.ple  V»<'«'^P;^'^t'^'^/5'^*>^ !  ;, T^j 
ation.  (n)  j.hvsiological,  an<l  (b)  pathological.  Ihe  first  is  exemplified 
in  bacterial  intoxications.  Physiological  fatty  degeneration  is  seen  n^ 
the  cells  of  the  sebaceous  glands,  and  m  the  formation  "f  .th^/«*  J^^  ^^ 
lets  of  milk  from  the  cells  of  the  mammary  gland  in  which  there  r  j 
multiplication  of  cells,  those  nearest  the  umen  ^'^^^'"/"f  j^"\,'"; 
being  disintegrated  off  as  a  mass  of  fat  globules  ^''-itl"'!"^ ""f  ''^ 
tlegeneration  i<  ^een  in  certain  r-ases  of  acute  intoxication  ^^f  ^ 
bacterial,  such  as  poisoning  by  certain  chemicals  and  ">  ^^'^ '  ' ;' " 
trition  of  starvation  or  of  the  extreme  anemias.    1  here  xs  no  cert.unt>, 


LII'OID  DEPOSITS 


305 


(if  (i(iir>f,  that  any  or  all  iif  tlit'st-  fatty  (If^jt'iu-mtions  ar«'  not  pri'crdtMl 
li\  I  liiiiily  s\velliii>{. 

Lipoid  "Infiltration"  and  "Degeneration."-  \\v  imve  said  that  the 
ai'iKiiniiKf  of  the  (rlls  of  tht-  cortex  (>.  acln-iial  appears  at  first 

-i^lit  to  resemble  fatty  (lej;enera'!on  (see  Vlate  V'llI,  Fijt.  2).  The  work 
(i(  the  last  few  years  upon  the  lipouls  has  denioiistrated  that  here  we 
(Icil  not  with  the  aeeiiiiiiilation  of  neutral  fat.  hut  with  globules  whieh, 
unlike  iliose  of  the  neutral  fats,  are  found  doubly  refractive  under  the 
IHiliirizinj;  niieroseojH'.  Some  neutral  fat,  it  is  true,  nwiy  be  present,  but 
tlicM'  cliiiracteristie  >;h)bules  are,  aecordinn  to  reeeiit  investigations. 
f(iriiit<l  ill  the  main  of  eholesterin  esters,  more  particularly  of  cholesterin 
olciite.    Similar  iloubly  refractive  granules  are  f(jund  in  very  many 


Fio.  IM 


Ktu.   155 


JtiHf  i*\|,rfsj.fti  frimi  adrecel  cortex,  wen  under crtjssed 
Nif  "1'- pii^iMs  hlHiwiiiK  isotropous  fatty  Klobulca  ami 
^itii-n.  [. Mi\*flin  iflobules  (with  Ijiack  rross). 


Hydropir  df>f;<'neruti(in:  epithelium 
Irom  11  snijtllpdx  papule.  Tlie  epideniia) 
cells  greatly  (twolten,  difltended  by  large 
vacuoles.      X  300.     (Ribbcrt.) 


toll- 

.It-, ' 

tir- 
11  I.- 

ii,,„: 
iifti' 


I'  flic  Ixxly  in  tlcgenerative  processes,  notably  in  the  atheronia- 

icins  of  the  aorta,  in  degenerating  cancer  cells,  and  in  areas  of 

:!ii()ii  ill  the  nerve  tissue.    In  fact,  more  than  one  of  the  lipoids 

•vi\  the  ajjpearance  of  double-refraction.'    One  of  the  simplest 

'  -t  f.\aiii])les  of  the  existence  of  these  doubly-refractive  so-called 

■  lrii|)l(ts  to  study  is   in  the   sputum  of   adults  coughed   up 

M     inoriiiiig.     It  seems,  therefore,  that  just  as  we  may  have 

I  tatty  "infiltration"  and  "degeneration."  .so  also  we  may  have 

iiililtratioiis"    and    "degenerations."      This   subject   is   being 

'uilicd  at  the  ]>.   ^ent  time,  its  chief  interest  lying  in  the 

'  twteii  the  lipoids,  and  the  proteins,  many  of  the  former 


See  also  p.  20  for  cla.isification  of  liiwids. 


^f ^^^ii*: 


;{(Mi  TIIK  HEailf:SSlVt:  TISSrK  (IIASaKS 

n-simhliiiK  tin-  iiiu  liiiis  in  posMSHiiiK  lM)tli  tiitrnK«'ii«ms  ami  phosphcric 
riulirlfs.  aii.l  sunp-stiiiK  stroiijtly,  staK»'H  «'itluT  in  tlir  huil.hiiK  up  or 
«liss«K-inti(m  of  IkmIIi-s  of  the  lattor  onlir  witliiii  tlif  roil. 

Glycogenous  Infiltration.  \\v  liavf  littU-  kiiowltMlm'  of  tin-  sijtmfi- 
cance of  Kl.vio^jfii  in  tin-  tissm-s  in  ahnonnal  situations  or  amounts.  It 
is  found  inu  oonsiderabU'  nunihtT  of  rapiilly  Krowinn  (TJIular  m'oplusnw, 
as  again  in  HtnU's  tuhult-s  of  tlu-  ki.infv  in  oases  of  (lialn-tt-s.  It  has 
h«rn  found  also  in  pus  crlls.  •       i     ■  i 

Hydropic  Degeneration.  Cloudy  swilling  U-ma  ass(Kiate«l  with  an 
incnase  in  tiie  watorv  contents  <.f  the  .til.  then-  art-  oxtrt-inf  khuU-s 
of  this  in  whioh  actual  vacuoles  appear  in  tlu-  cyt..i)lasm;  these  watery 
vacuoles  nn.v  increase  in  size  till  the  cell  hursts;  the  accuniulate.1  fluid 
from  the  hurstiuK  of  several  contiguous  cells  may  then  form  vesicles. 
The  m.)st  extreme  examples  of  this  are  the  "imkUs"  in  smallliox,  where 
the  deeper  layers  of  the  epidermis  Ix-come  hydropic,  swollen,  ami 

disintegrated.  ...        ,         n  •  i  i      ^     i 

The  explanation  of  siah  absorption  is  that  the  colloidal  outer  laser 
of  the  cell  which  repres«-iits  the  cell  merahraiie  of  plants,  ordinarily 
prevents  the  diirusion  <.f  crvstalloid  niole<-ules;  that  crystalloid  mole- 
cules do  appear  hv  some  .lisorganization  of  the  cytoplasm,  and  as  Ioiir 
as  these  exist  in  the  cell  hody  in  greater  c«)iicentration  than  in  the 
surnmiiding  metliiini,  wat.-r  will  diffuse  inwanl  until  equalization  omir*. 
Thus  the  cell  swells  up  and  Lccomes  hydropic.  In  addition,  Martin 
Fischer  calls  attention  to  the  fact  that  increased  acidity  of  a  colloulai 
menstruum  leads  to  an  increased  imbibition  of  water. 

Vacuolar  Degeneration  is  seen  in  muscle  and  nerve  cells,  and  is  char- 
acterized by  the  ai.pearance  in  the  cytoplasm  of  vacuoles,  which  are 
presumablv  caused  by  an  osmotic  absorption. 

Serous  Atrophy.-  This  has  alrca<ly  been  «lealt  with  under  atrophy; 
cells  and  intracellular  tissue  alike  absorb  a  serous  fluid  which  rei)laces 

prwxisting  fat.  ,, 

Dkgfnkkvtions  Assck  iatki)  with  thk  Dkposit  of  CoMPoi  nd  1  R<>- 
T,,,.,xs  —There  is  a  series  (.f  ill-understood  degenerations  in  which  apin-an 
in  the  tissues  material  that  in  1- •  unstained  condition  is  trans  iK^nl 
or  glassv;  when  colorless  and  firm,  we  call  this  hyaline;  when  eolor-i-s^ 
and  fluid  or  semifluid,  mucoid;  when  semisolid  or  solid  and  of  n» 
appearance  of  glue,  coUoid.  Hyaline  and  nuc.i.l  were  ""fe/;-*""'"'^ 
as  specific  substances;  but  we  know  now  that  what  is  calleo  hyatine 
for  example,  mav  be  pnMluced  in  difTerent  ways.  Amyloid  is  an  evcep 
tion,  and  from  its  staining  reactions  seems  to  be  a  separate  entiiv 
These  substances  are  proteins;  and  in  a  molecule  as  large  as  e\.n  in 
simplest  protein  molecules  are,  it  will  be  readily  understoofl  that  J 
comparativclv  small  change  such  as  a  few  more  or  less  carbon  Mom 
or  a  few  more  or  less  oxygeu  atoms  may  be  the  cause  of  a  oonsule  am 
change  in  properties;  and  these  lower  proteins  are  only  thus  far  reuu>Ne( 
from  ordinary  protoplasm. 


Pl.AI'E  VI  H 


Fntt  V    Dt*qf'n^r'Mi  i<  >n. 


'  !t-.t,.tift:ili.»n   < .(    .  «-ll-.   i>t    ? 
.t   ;  H  1  tie  ,   -III  tfrv»Mi  1 1  u|   n  1 1' 


>l  I  V  <  Jt  I  Itc  I     t  I  I  till  If 


if  lli»»  ki()  tii»v,  InnM 


■^tni  iiecl 


S\u 


III 


KUi     U 


Li  |)(>i(l    Infiltr'aiion. 


i(»  JKJreniil   ireHtetl    willi  Smhiii    III,  to  -,h«»w   a 


4M  uniiiliil  iMi  1 


III   the  <eils  of  Hie   zona    ruscieulatH.      These   ^tlohule^  twt 


'  li'>*"itt"-.   ;ire  aht  iiirlniit 


ircc    from    lipoid    iiUihuics 


r*.    cell    rotmr. u- 


'iWML-.m^f^i^^^^^m 


■«!J 


MUCOID— COLLOID— AMYLOID 


307 


Mucoid  Deposits.     Mucoid   Degeneration  and   Mucinous  Deposits. — 

The  iniiciiis  arc  filycoprotfins,  coiiinoiinds  ht'twi-fii  proti'in  and  car!)!)- 
Ii\  ilniic;  tlu'v  arc  laid  down  in  the  body  intracellularly  and  intercellularly. 
I-Aiiinplcs  of  tlio  first  are  seen  in  the  salivary  filands  and  the  jjohlet 
(ills  of  the  intestines,  and  of  the  second  in  Wlirrton's  jelly  in  the 
iiiiiliiiical  cord  and  in  the  nmcinons  intercelhil'':  'h..:i!\  of  embryonic 
li--iit  s  in  j;eneral.  In  either  ease,  nuicin  is  vise.  I,  swells  iii*  uii  i  water, 
i-  Miluble  in  weak  alkalies,  and  is  ])recipitat<  1  b.  a<eti(  a  u  or  by 
iiIcoIkpI.    Basic  dyes  stain  it. 

Intracellular  Mucin  Formation.  Mucin  is  tlui;.  |,i.-.li.  .i'  in  eatiirrhal 
-iMtc-  of  mucous  membranes,  in  which  not  oiilx  is  there  active  ])roduc- 
tii'ii  of  nmciu  b\-  goblet  cells,  but  also  a  dej;eneratioii  of  individual 
nlN,  in(  ludiuji  t!ic  niiclcns,  by  which  the  entire  cell  substance  chauftes 
111  iiiiicin.  Mucin  as  sucii  does  not  apjjcar  in  the  healthy  cell,  bnt  nnicin- 
iii;(  11.  its  i)recnrsor,  may,  and  nnicin  jjroduction  occurs  with  a  previous 
|iriM  tss  of  cell  di\  isiou  which  is  like  that  seen  in  secretion  in  the  main- 
iii;ir.\  inland.  .\  more  acti\'e  production  is  that  seen  in  the  so-called 
colloid  cancers,  an  unfortunate  term, as  the  material  is  inspissated  mucin; 
ilii-'C  j^rowths  orifiinatc  from  tin-  intestinal  nuicosa,  the  tumor  cells 
uiiil(ri.'oiii^'  a  complete  transformation  into  mucinous  matter. 

Intercellular  or  Interstitial  Mucin  Formation.  This  may  be  found 
l':iilHi|(ij;ically  in: 

1 .  Senile  atrophic  tissues,  as  in  the  cartilaj^cs  and  bones  of  the  old. 

-'.  The  connective  tissues  in  the  early  stajjes  of  myx(r<lema.  It  was 
at  lir-t  tiiou^'ht  that  increased  interstitial  mucin  was  a  constant  change 
ill  tlie  subcutaneous  tissues  in  atrophic  diseases  of  the  thyroid,  but  in 
V<\\z  per>istin<r  cases  the  mucin  is  foinid  to  diminish  with  coincident 
ile.i  lupmcnt  of  fully  formed  connective  tissue. 

;.  Aitivcly  de\eloping  tumors  of  the  connective-tissue  type,  sar- 
ii'ina^.  tibronias,  anil  in  the  interstitial  tissue  of  carcinomas.  Mere 
'1  ill  iiui  of  tumors  is  often  mistaken  for  a  mucoid  degeneration. 

!    nexclopitif;  i;ranulation  tissue. 

Ill  iill  tliese  circumstances  it  will  be  seen  that  we  deal  with  either 
11'  n\e  tissue,  or  with  immature  tissue,  or  with  tissue  reversion. 

Colloid.  Dense  colloid  dej)osits  are  relatively  rare.  The  typical 
'  inplr  is  the  gluey  or  almost  solid  accumulation  within  the  distended 
i'  le>  of  the  enlarged  colloid  goitre;  similar  material  may  show  itself 
i  I  -ides  of  the  pituitary  The  next  most  common  site  is  in  the 
i:  iiry  tubules  in  certai.  ases  of  chronic  nephritis,  the  tubules 
' '  'iiiiig  plugged  with  dense  hyaline,  or  more  accurately,  colloid  casts 
*       !i  tiike  on  a  deep  stain  with  the  ordinary  staining  n-agents. 

'  myloid.     This  is  a  material  allied  to  the  matricial  matter  of  cartilage, 

'  't  found  in  normal  tissues.    When  it  is  present,  it  has  a  character- 

aiii)earance  and  well-marked   individual  reactions.     It   may  be 

'  ili/ed,  affecting  several  organs,  or  localized,  affecting  a  relatively 

'  area  of  inflaminatury  or  neoplastic  growth. 


W- 


808 


THE  RKaRESSIVE   TISSUE  CHANGES 


Generalized  Amyloid;  Amyloidosis.  When  advaiurd,  this  affects  a 
larjjo  mimlHT  of  orj^aiis,  fsi)e(ially  the  spleen,  Hver,  and  kichieys.  Tlie 
only  tissues  that  have  not  heen  t'ound  affected  are  the  epidermis  the 
cutis,  hone,  huij:  tissue,  and  nervous  tissue  proper.  If  tiie  spleen  and 
liver  he  free,  it  is  useless  to  search  other  or^'ans  for  it.  The  affected 
spleen  is  enlarged  and  more  dense  and  firm  tiian  usual.  On  section  it 
lias  a  semitranshicent,  waxy  ai)pearance  (hence  the  terms  waxy  or 
"bacon"  spleen),  this  being  ditFuse;  or  rounded  areas  are  seen  on  the  cut 
surface  of  the  size  and  appearance  of  sago  grains  ("sago  spleen")  the 
affected  parts  being  the  Malpighian  bodies.  The  ajjpearance  of  the 
liver  and  of  the  kidnc\  is  by  no  means  so  characteristic,  but  the 
reactions  can  be  readilv  demonstrated. 


Fia.  156 


Fig.   157 


^    '^ 


\c 


Ant\l<»iil  lii'i^riicratkin  affi-ctinK  tin-  liii-r; 
sliKlilor  grade;  the  cells  are  .•.till  preseni  with 
hut  inoHerate  atrophy;  the  irremilar  depo.^il  <ii 
atii.v'liiiil  aroiMui  the  i-ajjillaries  i^  \V4'11  irihrked, 
(.\fter  Hihhert  ) 


.\lrivlf)id  tiejreneration  of  liver,  advanced:  u. 
atrf>iihied  liver  eella;  h.  tran.sverse  section  of  a 
(;apillar>-  surrounded  liy  a  hroad  ringof  amyloid 
material;  r,  a  capillary  c»it  longitudinally, 
(liihhcrt  ) 


Rf(i(ii(»i.~  On  tile  cut  surface  of  the  organ  washed  free  from  blood  is 
poured  diluted  tincture  of  iodine.  When  the  surface  has  assumed  a  pale 
yellow  tint  the  amyloid  will  ha\e  a  brownisli-rcd  color;  if  now  a  .">  or 
10  per  cent,  solution  of  suli)huric  acid  be  poured  on,  the  amyloid  becomes 
violet  or  black,  the  rest  of  the  tissue  remaining  relatively  unaffected. 
The  same  method  may  lie  applied  to  the  microscojiic  examination  of 
sections  cut  from  the  frozen  tissue,  the  affe.  T?d  parts  showing  clear  and 
yellowish  by  transmitted  light.  Kveii  more  distinctive  in  sections  is  the 
use  of  watery  methyl  violet,  followed  by  washing  in  very  dilute  hydro- 
chloric acid;  this  applies  to  fresh  or  alcohol-preserved  material,  mid 
shows  the  amyloid  as  ii  rr)se-pink  mass  against  a  slaty  backgrouiul. 

The  deposit  of  amyloid  occurs  in  the  walls  of  the  capillaries,  just 
external  to  the  endothelium,  and  in  th"  larger  vessels  the  connet  tive 
tissue  of  the  media  is  th«'  iiart  affecteo.  The  amyloid  is  laid  down 
(piite  irregularlv ,  so  that  a  ves.sel  may  look  iop-si<led  fay  reason  of  this 
iiiec|uality.    The  results  to  the  tissues  of  the  laying  down  of  amyldid 


iftfR 


"^xmrnssF 


Il> 


ELASTOID—H  YA  USE 


309 


m-  twofold:  the  lumen  of  the  vessel  is  encroached  upon,  and  the* 
ti-iics  are  thus  ill-nourislicd,  as  u  II  as  subjected  to  pressure  by  the 
l>liysical  presence  of  the  amyloid;  ultimately  the  original  tissue  may  be 
iiliiiost  destroyed.  Amyloid  deposits  are  made  in  the  body  during 
thr  course  of  long-continued  drains  upon  the  system,  especially  when 
till-;  is  a  sociated  with  an  excessive  product'  ■'  and  an  excessive  waste 
III'  iciikocya's,  altliotigh  a  protein  discharj,^  y.!  any  sort  will  produce 
the  elfVct.  ChrcMiic  bone  tuberculosis  with  cold  al)scess,  osteomyelitis, 
^xpliilis,  leukemia,  Bright's  disease,  or  even  prolonged  lactation  are 
-I line  of  the  states  that  produce  it. 

Localized  Amyloid. — This  is  seen  in  localized  granulomatous  masses 
"f  tuberculous  or  syphilitic  origin  and  in  coimective  tissue  tumors, 
Imperially  (tf  the  head  and  neck  region.  In  such  sites  the  small  blood- 
ussels  are  relatively  unaffected,  the  amyloid  being  laid  down  in  the 
interstitial  tissue,  perhaps  along  the  lymph  channels. 

The  Nature  of  Amyloid.  The  blue  color  with  iodine  and  sulphuric 
;i(iii  led  to  the  supposition  that  amyloid  was  related  to  starch,  whence 
Its  iiiiiiie;  but  its  protein  nature  was  soon  shown,  although  the  name 
iHT-istfd.  It  is  a  glycoprotein,  containing  chondroitin-sulphuric  acid. 
Tlii-  material,  brought  by  the  bloofl  or  lymph,  probably  diffuses  out 
tliroiigii  the  walls  of  the  vessel  and  meets  a  local  protein  with  which  it 
<niiil.iiies.  In  composition  it  is  somewhat  allied  to  the  chondrin  of  car- 
\\\\\'^^-  and  yellow  elastic  tissue,  which  also  contain  chondroitin-sulphuric 
aeid.   Thus  chondroid,  rather  than  amyloid,  would  be  tlie  accurate  term. 

Elastoid.  -We  have  separated  off  from  the  group  of  hyaline  degenera- 
ti(m>  iuiother  form  seen  often  in  the  uterus  after  delivery  and  involution, 
in  winch,  especially  at  the  region  of  the  placental  site,  arteries  more  or 
le>-  (ihlitcrated  are  to  be  recognized  as  glistening,  hyaline  masses.  The 
remit  studies  of  our  colleague.  Dr.  (ioodall,  have  shown  that,  associated 
tt  It  li  the  narrowing  of  the  lumen  of  the  much-dilated  vessels,  the  internal 
dustic  lamina  undergoes  a  most  remarkable  process  of  swelling  and 
t'll'liiii;  upon  itself.  At  first  the  swollen  elastic  tissue  reacts  with  Wei- 
j-'eri  s  .lastic-tissue  stain;  in  a  later  stage  it  no  longer  gives  this  reaction. 
1  lie  remarkable  fact  is  that  within  these  swollen  masses  a  newer,  smaller 
iirteiia!  lumen  is  developed,  which  may  become  surrounded  by  all  the 
:irt(  riiil  (^)ats,  intima,  media,  and  adventitla,  whereas  to  the  outer  side, 
til'  prcMously  h.\pertrophied  media  undergoes  complete  degeneration 
jiii'i  al.s<>ri)ti()!i.  In  this  way  the  arteries  adapt  themselves  to  the 
I'- 'lied  demand  for  blood  by  building  what  mav  be  an  entirelv  or 
iwrniillv  new  artery  within  the  lumen  of  the  old. 

Hyaline.    Of  the  other  ortlers  of  hyaline,  which  still  retain  this  name, 


th. 

III;! 
ti- 

iiip. 
tihr 


■ini.iDncst  is  that  foun<l,  apparently  as  a  persistent  necrobiotic 
.  Ill  association  with  connective  tissue,  though  other  tissues  also 
'"  involved.  Examples  of  this  are  to  be  seen  in  the  connective- 
truniework  of  the  thyroid  and  kidney  in  cases  of  so-called  chronic 
'itial  intfammation.  Here  relatively  large  tracts  of  thickened 
tissue  may  assume  a  glassy  appearance  with  great  paucity  of 


310 


TliK   liKdliE      IVF.    TIASVK  C/I.Wf.ES 


\uh\v\.    Some  of  tl.c  !;irf,'cst  iircas  are  strii  in  tlic 
ot"  so-ciillcd  clironi'  in\ 


ociinlitis  HI 


tlif  f 


matter  iiit(Ti)()st'(l  in  the  mass  of  still  imcli 


myotanliiim  iii  case 
fli 


nrm  ol  irrefinlar  areas  ot  livalii 


he 


iaiij;e(l  muscle  tissue;  possil)ly 


I"lu.    luS 


Klaatoiil  ilcKmoralion:  Soction  of  siimll  artiry  irdtii  bi-nt-atli  pla(cnt;il  site  of  utcTus  cxhil.liine 
Miliiinolulio.i.  The  paiu'iit  sulTrrccI  from  renal  an,l  hi-patii-  ilislurlianc.s.  iin.l  died  wvi.n  ii,„i,ilis 
after  delivery.     Seetion  .-taini'd  bv  WiiKorf.-  eiastie  anil  Van  Gii'son'."  .■.tiuns.     (Dr.  Uoodall.) 

Vitreous  hypertrophy  of  elastica  interna  at  .,,-  vitreous  decenerution  <,f  the  same  at  t;  at  c.  transili.m 
fron,  stained  hypertrophic  to  unstained  d.'iien.Tated  elastica:  .1.  lumen  of  the  new  vessel  surrounded 
iiy  irregular  new  luuseular  and  intin.al  tissue;  at  ,,  renjains  ..f  old  media  with  hypertrophy  ..f  its.  el,,Mir 
lihres;  outahle  the  degenerated  elast  ca  interna  at  fthe  ainjphy  ,.'  .he  media  is  more  extreme. 

Tiii.   i:>!) 


Hynlinp  deueneration  of  a  ((lonierulus.  from  a  kidney  showing  ebronic  interstitial  nephritic. 


■jp'j^j^xcjsnp^.i 


IIYM.ISE 


311 


li.  re  we  (leal  not  miToly  witli  a  <liaiij;c  in  tlu>  lihroiis  tissue  which  has 
n  |.lii(i-(l  (lead  inusclf  fil)ros,  l.ut  with  a  hyaHiic  traiisroriiiation  also  of 
nnixlf  trils  whose  imtrition  has  hccii  cut  otV  throiijrh  ohhtcration  of 
the  arterioles.  Jn  several  orders  of  tumors  there  is  a  siniila.  hyaline 
ii((  rohiosis  of  cells  farthest  removed  from  the  nutrient  vessels;' these 
tiiiiiors  then  assume  the  appearance  known  as  cylindromatous.  A  like 
hvaline  change  may  also  affect  the  organized  fibroid  deposits  on  serous 
Mirtiice:;,  the  new  connective-tissue  growths  of  granulomas  and  even 
."il)iilary  walls.  Of  this  last,  the  most  noticeahle  example  is  seen  in 
the  hyaline  chmips  which  represent  the  glomeruli  in  cases  of  chronic 
interstitial  nephritis  (Fig.  1.")!)). 

Fiii.   KK) 


J.G.A. 


Ill  ilir,.   tl.ri.iHhus  in  diluted  vinulc  of  hemorrhoid.    This  was  perfectly  honmgeneou*      Ueichert. 
ol>j.  7a.  oeular  i.     Camera  lucidu,  rediieed  one-third. 


Hematogfenous   Hyaline    (Hematohyaloid).-  Of   this    form    the   type 

>le  is  seen  in  hyaline  thrombi  due  to  the  intravascular  and  intra- 

"iigiiitination,  either  in)  ol  the  entire  red  corpuscles,  as  under  the 

•if  agglutinin,  or  {}>)  of  the  ^  me  after  a  preliminary  disintegraticm 

iiiidler  glo^  ular  masses,  or  {r)  of  blood-platelets."    Oc^- •  •  onally, 

nnog..|!.(.,„itainiiig  serous  exudate,  instead  of  forming  .  .e  char- 

i  lie  fine  fibres  of  fibrin,  undergoes  coagulation  in  the  form  of 

ciiieiiis  hyaline  ma.s.ses.    This  seems  to  be  an  allied  condition. 


tWIil 

vli.ii 
111'''  'I  (I 

ill'!  I; 

ho;,;, 


r,,-"--^,,  Z*»f«>—'!5f^^ »' 


312 


THE  REORKSSIVE  TISSUF!  CIIASGKS 


1-; 


m 


Hyaline  Casts.  There  is  still  ilclmte  ri'jjHnliiij:  th<'  luoile  of  origin 
of  the  tratisi)areiit.  scarce  visible  casts  seen  in  tlie  urine.  Some  autlior- 
ities  reftanl  them  as  the  result  of  coagulation  of  oonstituents  of  the 
bloofl  escaping  into  the  tnhules,  and  in  favor  of  this  view  there  is  that 
at  times  those  have  been  seen  in  parts  to  take  Wei);ert's  fi[)rin  stain. 
(Hhers  regard  them  as  more  commonly  the  result  of  fusion  and  inspissa- 
tion  of  discharfres  or  broken-down  matter  from  the  e{)ithelium  of  the 
tubules.  Where  there  is  more  extensive  disintegration  with  liberation 
of  coarser  portions  of  the  cell,  a  granular  cast  is  produced;  where  the 
t'utire  cells  in  the  course  of  acute  infianunation  become  cast  off,  there  is 
formed  the  cellular  or  epithelial  cast.  Where  the  disintegrated  material 
detained  within  the  tubule  undergoes  progressive  inspissatu)n,  there 
is  developed  the  colloid  or  waxy  cast. 

Intracellular  Hyaline.— Especially  in  the  study  of  cancers  there  have 
been  noted  small  globular  or  irregular  masses  within  the  cells,  having 
the  appearance  and  reaction  of  hyaline.     A  series  of  cases  has  been 
described  showing  various  gradations  of  staining  power  (and  therefore 
of  chemical  composition).     Of  these  the  most  familiar  examples  are 
the  Russel's  fuchsin  bodies  (Fig.  11.")),  so-called  because  they  fix  fuchsin 
with  con- Iderable  intensity.    These  originate,  apparently,  within  the 
cell  in  cases  not  merely  of  cancer  but  also  of  chronic  inflammation. 
Often  through  degeneration  of  the  cells  they  come  to  be  extracellular. 
Pathological   Keratinization.— This   is   an    allied    condition.     The 
normal  epithelial  cells  of  the  skin,  as  they  come  to  lie  farther  and  farther 
removed  from  the  :\Ialpighian  layer,  exhibit  when  they  reach  the  level 
of  the  stratum  granulosum  fine  graimles  of  keratohyaline.    These  stain 
blue  with  hematoxylin.    In  the  stratum  lucidum  these  become  trans- 
lucent and  are  seen  to  be  evenly  diffused  througliout  the  cells  (eleidin). 
Further  outward  is  to  be  seen  a  second  development  of  granules  of 
keratin  which  take  on  a  puip:ish-blue  color  with  Gram's  stain.    Passing 
still  farther  outward,  as  the  cells  become  completely  necrotic,  with  non- 
staijiing  nuclei,  they  become  represented  by  flattened  scales  of  compact 
keratin;  this  stains  yellow  with  van  Gieson's  stain.    Occasionally  we 
encounter  massive  accumulations  of  these   keratinized  cells,  as  for 
instance  in  the  middle  ear,  forming  pearly  masses  known  as  choles- 
teatoma, and  in  the  cutaneous  horns  which  may  show  themselves  on  one 
or  other  area  of  the  body  surface.    These  are  not  true  hypertro[)liits. 
but  abnormal  collections  of  matter  not  properly  cast  off.    At  most,  the 
underlying  rete  Malpighii  may  show  hypertrophy  and  indications  of 
increased  cell  proliferation. 

Hare  allie<l  conditio;;"  are  those  of  hyperkeratosis  and  ichthyosis, 
acquired  and  congenital  imperfect  growth  of  the  skin  accompanitd  In- 
thickening  of  the  keratin  layer.  Chronic  irritation  sometimes  leads  the 
tongue  to  preseiit  keratinized  processes  of  the  epithelium  (hairy  tongue), 
the  oesophagus  to  exhibit  longitudinal  bands  of  epithelial  thickening 
(leukoplakia),  this  notably  in  alcoholics,  and  the  vagina  to  show  homy 
ridges  (pachydermia). 


r£»sst-»E:''.^-'i',''S"!G— «K'7-e«m&7'5»'»H«HS2MT.'^j»^Ke*B^mas(* 


CALCIFfrATlOX  AND  CALCAREOUS  DEPOSITS 


313 


CALCinCATlON  AND  CALCAREOUS  DEPOSITS 

Almost  fviTV  order  of  tissue  may  he  the  seat  of  interstitial  deposits  of 
i.ilciiim  salts,  altlioiij;li  the  supportive  tissues,  such  as  cartilajre  and  the 
coiiiiective-tissues  of  vessels  and  of  orpins,  are  most  frequently  afteeted; 
tlic  i)arenehyma  of  glands  is  at  tiiues  liable  to  it  and  deposit  inav  ocenr 
iiitracellularly  in  the  nervous  system.  The  extent  of  the  <leposit  mav 
viiry  between  a  few  gritty  particles  m  a  r-iss  of  caseation  to  large 
Iiiiiips  as  dense  as  stone.  The  deposit  of  calcium  salts  has  little  in 
loiiunon  with  the  process  of  ossification,  although  in  this,  too,  calcium 
siilts  are  the  material  that  is  laid  down;  there  are  none  of  the  orderly 
priiccsscs  by  which  in  bone  the  calcium  salts  are  relate<l  to  the  bloocj- 
vcssels  ancj  the  matrix;  although,  according  to  Wells,  there  is  a  striking 
^iiiiiliirity  in  ratio  between  the  calcium  antl  nuignesium  salts  and  the 
liliosphnric  and  carbonic  acids  that  exist  in  bone  and  in  jjathological 
calcification. 

Microchemical  Appearances  and  Reaction —  In  the  smallest  masses  the 

calcareous  deposits  are  like  fine  rlust,  which  may  give  place  to  angular, 
crystalline  masses  or  even  globular  concrements.  Insoluble  in  ether  or 
caustic  potash,  they  dissolve  rapidly  in  acids  and  slowly  in  formalin,  and 
when  dissolved  out,  a  matrix  of  dead  tissue  is  left  in  which  histological 
cliaracters  are  not  to  be  distinguished.  Stained  with  hematoxylin, 
(•al(  arcous  material  takes  a  pronounced  dark  blue  color.  Treated  with 
a  .")  jicr  cent,  solution  of  silver  nitrate  for  five  minutes,  with  subsequent 
txpoMirc  to  the  air,  metallic  silver  is  precipitated,  causing  the  granules 
•  •'■  (al(  arcous  material  to  stanfl  out  as  coal-black  dots,  in  consequence  of 
tiic  action  of  the  phosphates  present.  Treated  with  acid,  there  is  an 
<\(>liition  of  bubbles  of  gas-carbon  dioxide-  indicating  the  presence  of 
(•ar<:nni  (and  magnesium)  carbonates.  Sulphuric  acid  causes  the 
ap|i«iuaiice  of  fine  crystals  of  calcium  sulphate  (gyp.sum). 

''.•il.ification  may  occur  in  tissues  that  contain  "living  cells,  not  in  the 
lirnni  a//*  flwrnselvps,  but  in  the  inert  interstitial  matter  between  the  cells; 
It  iH ciirs.  that  is,  in  dead  or  necrcscent  material,  and  the  statement  may 
•'••  niadc  that  it  does  not  occur  in  living  functioning  cells.  The  state- 
'II' HI  1  iiat  calcareous  deposit  does  not  occur  in  living  cells  is  made  with  a 
kiKiw  I.  (Ige  of  the  apparent  exceptions. 

I'  niay  be  said,  then,  that  calcification  occurs  in  dead  or  dying  cells, 
anj    111  (crtain  interstitial  substances  such  as  the  matrix  of  cartilage, 
ulln^  tiastic  tissue  and  hyaline,  this  latter  change  being  especially 
NMth  other  senile  alterations.     Belonging  largely  to  the  former 
an    those  instances  that  happen  in  the  interstitial  tusue  of 
I  ir  organs  like  the  thyroid,  the  testes,  or  the  ovaries,  in  the  lungs, 
mhranes  of  the  brain,  and  in  scars,  and  most  of  all  in  the  arterial 
!'i  the  artirics,  calcareous  deposit  follows  hvaline  and  fattv 
'  ition  (necrobiosis)  of  the  media  and  the  hypertrophied  intima, 
'  111  the  elastic  tissue;  these  changes  may  be  shown  by  the  specific 


alli'< 

till  II 

\M!!I- 

ain' 


314 


THE  REHUKSSIVK  TISSCE  ClIASdES 


Km    Kil 


tests  wlu-n  wo  <liaii);«'  is  apjMirfiit  to  the  imkcd  oyc.  Kciually  liahle  to 
HJVf  »'xaiiii)les  of  siicli  calcificatioM  an-  old  infnrcts,  cliroiiic  iiiflatnnia- 
tioiis  of  thf  stTosa-,  of  tlie  walls  of  cysts,  aiul  of  capsules  around  foreij;ii 
bodies,  while  tlie  existence  of  calcification  in  old  suppurations  is  often 
seen.  A  |)erfe(t  example  is  seen,  too,  in  tlie  impregnation  with  linie 
salts  of  the  dead  fietus,  the  result  of  an  extra-uterine  ^'station  retained 
in  the  abdominal  cavity  (lithop»dion).  Kxperimentaliy,  there  uie  many 
chemicals  which  cause  calcareous  deposit;  this  action  has  been  studieil 
chiefly  in  the  kidneys,  where  the  <leposit  is  preceded  by  a  l)ionecrosis 
of  the  tubular  epithelium. 

Different  hypotheses  have  been  ))rou^'ht  forward  to  explain  the 
I)lienomenon  of  calcification,  of  which  the  most  satisfactory  appears  to 
be  that  esju'cially  elaborated  by  the  work  of  our  former  collea>:ue, 

Klotz.  Obviously,  't  is  not  a  pre- 
cipitation of  the  salts  norniiilly 
j)r»'sent  in  the  affected  areas;  the 
lime  salts  are  brought  to  the  i)art 
by  the  lymph,  and  in  dead  or 
dying  cells  or  in  the  interstitial 
material  of  low  vitality,  are  ren- 
dered insoluble  an<l  deposited. 
The  chemical  process  underl\itig 
this  appears,  in  some  cases  at  least, 
to  be  that  a  fatty  degeneration  of 
cells  is  accompanied  by  the  libera- 
tion of  fatty  acids,  which  coin- 
bine  with  the  calcium  in  the  lymph 
to  form  compound  calcium  soaps. 
In  this  combination  tht  weaker 
fatty  acids  are  replaced  by  phos- 
phoric and  carbonic  acids,  with 
the  subsequent  deposit  of  insol- 
uble calcium  phosphate  and  carbo- 
nate in  the  dead  tiss'.es.  The  compound  calcium  soaps  are  probably 
compounds  of  fatty  acid,  calcium,  and  a  protein  or  a  product  of  jjrotciu 
disorganization. 

In  the  latest  work  on  this  subject.  Professor  Wells,  of  Chiciifio. 
while  admitting  the  foregoing,  regards  it  as  the  more  uncj)mmon  mode, 
and  brings  forward  not  a  little  evidence  to  show  that  hyaline  cartiluge 
and  homogeneous  hyaline  degenerative  material  possess  an  affinity  for 
calcium  not  exhibited  to  an  ecpuil  degree  by  other  tissues,  so  that  in 
faxoring  circumstances  the  calcium  salts  are  "adsorbed"  from  the 
lymph  until  they  come  to  be  in  such  concentration  that  they  are  pre- 
cipitated in  the  same  projjortions  as  those  in  which  they  exist  in  the 
circulating  medium.  lie  admits,  however,  that  the  factors  cnmt  rued 
in  this  process  of  precij)itation  are  not  wholly  known,  suggesting  that 


Section  of  aorta  of  ildi>rl.v  individual,  treated 
by  von  Kossa'a  nielliud,  to  demonstrate  ealeifi- 
cation  of  media,  and  moro  particularly  of  tlie 
muacular  bauds.     (Kloti.) 


■pHi 


IHPP«P 


CALCIFIC \rios  .\si)  ('M.c.\Rt:ors  DKrosirs 


aiT) 


I i'lly  11  rt'diictioii  in  the  iiinouiit  of  carhoii  dioxidf  or  soiiu-  otlier 

;i-i  iKv  iiidiKTS  tlif  prfcipitatioii  of  calciimi  salts  in  a  colloid  matrix. 

Concrements.  In  aildition  to  tins  deposit  of  caliari-ons  niatcrial 
ill  the  tissu  s,  tliiTf  may  Im-  a  deposit  of  tlit-  sanu'  in  ducts  or  jiassancs, 
li;iilinK  to  1  (If  formation  of  soli(l  masses,  round  or  oval  or  taking  tlie 
>liiil>c  of  the  duct  in  which  tln-y  arc  found.  These  are  termed  concre- 
ments or  calculi,  the  same  term,  unfortunately,  heinft  emj)loyed  hoth 
lor  I  he  almve  calcareous  deixisits  and  for  deposits  due  to  the  aliiiormal 
|in(  ipitation  of  specific  excretions.  Concrements  of  the  first  order  will 
111  I'nund  to  contain  an  amount  of  calcareous  salts  in  excess  of  that 
iiMiiilly  [)resent  in  the  fluids  dischar^red  alonj;  the  passage  coticerned. 
On  dissolving  out  the  salts,  there  is  left  a  matrix  of  mucinous  material, 
iiMi.illy  mixed  with  fatty  acids,  soaps,  and  cholesterin.  Such  concre- 
iii(iit>  arise  generally  as  a  result  of  a  catarrhal  inflammation  of  the  passage 
ill  (|iicstion,  wherehy  nuicin  is  exuded  and  some  of  the  cells  exfoliated. 
Tin  (li>integration  of  the  latter  affords  the  products  of  jmtteolysis  and  the 
ffitty  material,  and  in  this  as  a  matrix,  just  as  in  necrotic  tissue,  there 
i-  ,1  deposit  of  calcium  salts,  hy  diffusion  into  the  mass,  of  serum  from 
till  inflammatory  exudate  and  of  the  secretion  nornud  to  the  passage. 
Of  these  concrements,  the  following  are  worthy  of  note:  rhinoliths  in  the 
M.iNil  i)assages  after  ozena;  tonsillar  concrements  forming  in  the  crypts; 
salivary  concrements  formed  in  the  salivary  ducts;  l.icrimal;  cutaneous 
tonned  in  sebaceous  ducts);  preputial,  following  phimosis,  with  accu- 
iiiiihited  smegma  as  a  t\)Uiidation;  and  appendical  concrements  which 
lKi\e  as  a  base  rolled  up  and  compressed  fecal  matter.  Pancreatic  con- 
iTi  inents  are  of  widely  varying  c(mstitution,  this  depending  probably 
ii|>iin  the  length  of  time  during  which  the  concrement  has  been  retained; 
I  nient  line  will  show  abundant  products  of  cell-disintegration,  while 
ill!  "Ill  one  will  be  largely  composed  of  insoluble  salts,  a  distinction 
wiiK  h  may  be  considered  to  hold  not  on'     for  pancreatic  but  for  ail 

•  iiiMTi-ineiits. 

Phleboliths.  These  are  small  oval  stones  formed  in  veins,  chiefly  in 
till  uterine  ph'xus  in  the  female,  and  the  prostatic  plexus  in  the  male. 
itions  may  be  found  from  a  comparatively  soft  to  a  hard  pearl- 
;  the  i)hlel)olith  arises  from  the  deposit  of  lime  salts  in  isolated 
t  irunibi  that  have  not  undergone  organization,  and  thus  lies  free  in 
'111  Ininen  of  the  vein. 

Calcareous  Incrastations.— Deposits  of  various  kinds  upon  surfaces 
niii  undergo  a  similar  impregnaticm  with  salts  derived  from  the  bmlv 
llMhK    The  commonest  exami)le  is  the  tartar  of  the  teeth,  of  which 

•  I'ltM  hid  debris  and  particles  of  food  form  the  foundation;  in  chronic 
<;>  in.  a  deposit  of  jjhosphates  may  occur  ui)on  the  mucosa,  while 
tor.  i,„  iMMJies  i„  the  tissues  or  cavities  of  the  bodv  are  apt  to  become 
>iiiii    rl>  encrusted. 

'  ill  nr  concrements  of  the  second  order  include  four  gioups— 
'""  ■   .'.  I'lliiiry,  and  yrunhitic  calculi,  and  coriumi  aiiiulacea. 


Alltrai 
like  liiidv 


^W" 


:\]i\ 


TlIK  RtUHlKSSIVK   TISSUK  CflAXdHS 


Fir.    ir.L" 


Urinary  Calculi.  Urinary  Lithiasis.  Any  of  tlie  usual  or  nnusiial 
salts  of  the  urinr  may  lie  precipitated  to  form  calculi,  ami  for  tliJN 
formation  certain  features  nuist  l>c  present,  \vlii<li  are  conmion  to  iiij 
tlitl'erent  forms  of  calculi.  The  calculus  must  have  a  nucleus  of  mucus, 
of  celUlehris,  or  of  forei>;n  matter,  such  as  hlood  clot  t)r  an  intr(tiluce(l 
foreign  body,  in  ami  uiuui  which  the  salts  are  tieposited.  Tlu-  rate  of 
this  deposition  will  depend  \ipon  the  rt'lative  amount  of  salts  present 
in  the  solution,  that  is.  the  eoi'centration  of  the  salts;  as  in  the  urine 
this  is  very  variahle,  the  rate  of  deposit  also  varies,  so  that  piriixls 
of  i)roj;ression  of  (lei)osit  may  alternate  with  |>eriods  of  arrest.  As  a 
conse(|uencc,  most  calcidi  are  seen  to  he  formed  of  concentric  lamina. 
."^ince,  too,  in  the  urine,  at  one  time  one  salt  may  he  present  in  excess, 
at  another  another,  it  pnerally  happens  that  layers  of  more  than  one 
sort  enter  into  the  formation  of  a  calculus;  mixed  calculi  are  the  rule 
rather  than  the  ••xccption;  and  in  iirinary  calculi,  the  jrrowin^'  stone  acts 
as  an  irritant,  infection  occurs  with  ])roduction  of  alkaline  urine,  so 
that  th«'  most  superficial  layers  may  he  j)liosphatic  in  luiture. 

'I'he  mere  pn-seiice  of  salts  in  excess  in  the  tirine  is  not  ade()uate  to 
explain  calculus  formation.    If  the  salts  he  dissolved  out  of  the  calculu>, 
there  is  left  hehind  a  matrix  of  organic  matter 
of  f^elatinous  '  >•  colloid  type,  yellowish  or  other- 
wise |)i>rmcnte-       nd  if  calculi  he  jiromnl  <lown  to 
nuikc  sections,  mter  the  manner  of  the  j;eoloj;ist, 
it  will  he  found  that  the  salts  arc  not  laid  down 
in  their  usual  crystalline  form,  a  fact  which  liad 
^^^  n    ^i'Y       heen  previously  noted  in  cfiji-shells,  hone,  etc. ;  tills 
^^S^ QfG\  )         appears  to  mean  that  there  is  first  of  all  a  muci- 
nous or  colloid  matrix  laid  down,  and  that  crys- 
Douiiif  r,mi.,urp,!  myelin     tallizatlou  ill  colloidal  solutioii  grcatlv  modifies  The 
';•"""'"'  '"t"''"  """"'"'     >liape  of  the  crvstals,  the  crvstals  tendinj;  to  he 

f*liai>c        with        pr.    ■.    srn  i      i    •  i        .  i  '     .       i  . 

(ivri»)  roinided  mstead  ot  anjj;ular.    .^uch  a  mucmous  or 

colloid  material  is  thrown  off  in  inflammator.x  states, 
ami  the  greater  its  amount,  the  greater  is  the  liahility  to  precipitation  of 
the  salts.  Thus  for  the  fornmtion  of  urinary  calculi  it  seems  necessary 
to  have  three  fa(  tors:  ( 1 )  the  presence  of  a  cr.\  stallizahle  bod.v  in  excess 
in  the  urine,  and  Cl)  irritation  of  some  part  of  the  tract  leadiiij:  to 
increased  discliarj;e  of  nuu'inous  matcTial,  and  {:>)  some  solid  body  wliicli 
will  act  as  a  nucleus  on  which  precipitation  occurs.  The  irritation  iiiei! 
not  be  bacterial,  but  no  doubt  it  is  so  in  a  considerable  nunilxr  of 
cases,  and  if  not  so  at  the  outset,  the  irritation  caused  by  the  stone  will 
readil.v  lead  to  a  passinji  infectif)n  beinj;  picked  up. 

The  most  important  groups  of  urinary  calculi  are  the  uratic  (inclnding 
uric  icid),  those  formed  of  calcium  oxalate,  and  the  phosphatic. 

Uric  Acid  and  Uratic  Calculi.  I  ric  acid  is  the  commonest  coiistitiK  nt 
of  calculi,  wiietlier  a.^  llie  Uiain  or  a.>  u  subsitiiary  salt,  and  is  n./ri- 
common  as  uric  acid  than  as  amorphous  urates.  The  typical  urii  miil 
calculus  is  rounded  or  oval;  its  surface  is  smooth  or  finely  mamniiilalt<i; 


URINARY  CALCULI 


;?i; 


tli(  ciilor  varies  from  fiiwii  to  rini,  acconliiiK  to  tlic  ainoiiiit  of  unH-rvtlirin 
wliiili  is  hroiifilit  <lo\vii  in  tlie  urine  wlien  uric  aeiil  separates  out, 
:iiiil  on  seetion  the  stone  is  laininateil  (l*"ip;.  l(i.{,  Km).  Tliese  oeenr 
nbiiively  fre(inently  in  early  life,  and  a|)i«-ar  toon^riuate  in  the  pelvis  of 
till  kiilney,  whence  they  may  l)e  passed  while  still  smah,  is  (ravel,  small 
cilciili  of  a  reddish  tinjje.  |{emaininj;  in  the  pelvis  of  the  kidney  they 
iiiiiv  there  undergo  increase  in  size,  until  they  form  a  "stajjhorn"  mass, 
;i(  I  iiintnodated  to  the  shape  of  the  pelvis  of  the  kidney  and  its  l>ranehes. 


F(U.  163 


Kio    10.". 


)"io    164 


.'M'^ 


^^tri^^ 


I  i'.    RU  ^Cul.  iilus  formed  of  uric  aiiii  followed  by  oxalate;  appearance  on  section, 
l-i..    I'.J  — c>i:,|„t,.  of  linjp  calculus  ("niulhcrry"  calculus),  exterior  view. 

Ii'.    n:i      .\innioniuin  iiraie  followed  by  oxalate  and  eventually  by  mixed  phosphalea       (These 
inri'c  t:.-,j:.^  .-.r..  from  thu  ralaloKue  of  the  Royal  College  of  Surgeons.) 

Uratic  Inspissation  in  Infancy.- Autopsies  upon  infants  a  few  weeks 
"I'l  !rM|iuiitly  show  the  calices  of  the  kidneys  opacfue  and  whitish  or 
I'  finitely  streaked  with  yellou,  while  in  the  pelvis  a  few  reddi.sh- 
^r.iiiis  can  be  collected.    The  collecting  tuhtiles  contain  a  large 
■  "t   inniute  doubly  refracting  spherical  masses  of  urates  in  a 
iiiatri.x,  and  the  condition  has  been  usually  calle<l  uric  acid 

•  i'>s  suitable  term  than  uratic  inspissation;  the  masses,  chemi- 
'■"inposed  of  quadriurates.    Why  there  should  be  a  relatively 

•  iiarge  of  uric  acid  aiid  urates  in  the  very  young  is  not  und-r- 


fVfl! 

iirii'A 

llllll,! 

mill  i 

.ally 
yrcar 


tld'f^'W .~c  I«i 


3IH 


THH  HmiHKssivh:  tissik  ciiwuks 


Kli;     liiii 


sttMMl.  Imt  tluTf  scfins  pMxl  n-a^oii  I'nr  Mi|)|Misiii>;  that  inassi-s  of  tins 

sort  an-  in  part  rrs|Kiii>ililf  for  tlic  uric  ariil  calnili  ln'(|u«-iitly  fduml  i?i 

the  voiiiijr. 
Calcium  Oxalate  Calculi.     Tiu-  nid-^t  cnniminily  seen  of  caicimii  oxalatr 

calnili  arc  tiiosc  that  arc  callcfl  "mulberry  calculi."    Tlurc  is  a"  ho^c.l" 

or  iiiiill«'rrv-lik»' appearance  with  brown 
or  hiack  color,  and  on  section  the  lami- 
na- apjM-ar  laid  down  like  the  plan  of  a 
fortress  with  bastions.  In  compositidii 
it  is  founil  that  most  of  tlie  oxalate 
•  alcnli  contain  uric  acid,  w ith  suhstaiuis 
dcpo-ited  from  acid  urine. 

Phosphatic  Calculi.  These  niii.\  !>*• 
formed  only  of  calcinm  phosphate,  or 
of  annnonimn  nia>;ii<'siuni  phosphate,  or 
of  pure  ammonium  phosphate;  of  thcM' 
the  mixe<l  form  is  the  most  conunoii. 
All  arc  thrown  down  from  alkaline  urine, 
and  if  the  alkalinity  depends  on  sodium 
salts,  the  calcium  phos|)hate  stone  is 
found,  whereas  if  the  urine  has  hecoiiie 
alkaline  from  infection  and  fermentation 
the  triple  phosi)hate  is  likely  to  he 
found,  ^'ivinj;  rise  to  a  stone  that  is  of 
loose  cohesion  and  friable,  hut  which 
mav  be  of  larpe  size. 

Other  Urinary  Calculi.  Cystin  calculi. 
of  a  pale  yellow  color,  becominj;  j;reeu  on 
e.xjjosure  to  liflht,  and  of  soft  consist- 
ence, and  xanthin  <alcnli.  althoufrh  mtv 

rare,  arc  known.     Guanin  calculi  have  been  described  in  cattle,  as  well 

as  steatoliths  of  fatty  or  soapy  masses  in  man. 

Biliary  Calculi;  Cholelithiasis.  The  comjxisition  of  biliary  uilnili 
brings  it  about  that  they  are  less  dense  and  li^diter  in  weight  than  the 
\irinary  calculi;  they  are  composed  of  modified  bile  pigments,  cholesterin, 
and  at  times,  calcium  carbonate. 

CUixsificntinn.'  1.  The  Common  Gallstone.— This  may  l>e  sin>;l»',  Iar>;e, 
and  barrel-shaped,  the  ends  beinj;  face''  ',  or  there  may  be  a  Mnall 
number  of  relatively  large  stones  faci'  I  to  one  another,  forniinf; 
toKcther  a  cast  of  the  gall-bladder;  or  there  may  be  multiple  Mnall 
stones,  even  hundreds  in  number,  all  of  relatively  the  same  size,  p  iitr- 
ally  faceted,  the  faceted  surfaces  smooth.  The  color  varies  Irom 
black  or  deep  brown  through  reddish-brown  (bilirubin)  to  green  bili- 
verdin),  or  may  be  i)ale  yellow  from  superficial  layers  of  cholestcnn  of 
white  from  calcium  carbonate.  The  cut  surface  shows  coiKtuTric 
layers  of  varying  color  depending  on  the  extent  of  admixture  wil!;  tht 
calcium  salt  of  biliverdin  or  bilirubin;  the  nucleus  is  often  of  cholesterin. 


A  stiiK-horii  ralfiiliiH  in)  In  |H-iviH  of 
tlif  kiilncy. 


GALLSTOXKS 

2.   I'lirr   (or  nhiiont  purr)   Chnhiirrhi   Cnlnili. 


.'ilO 


Tlu'sr  ari'  init   very 

niiiimuii,  Hiiil  arr  usually  siiiKl*'.  oval,  pair  ydluw  stom-s,  with  a  waxy- 
jookiiijr.  Hiu'ly  niHliilar  surface.  Winn  l.roktir.  tlit-  siirfact-  is  crystalliiM-- 
liH.kiiik',  ami  tluTr  is  little  or  no  sijjii  of  stratifi<atioii.  It  is  (|iiit»'  ran-  to 
till. I  tlu'iii  al>soliit«-ly  piiH',  luit  !».*)  jmt  out.  or  iiion-  of  tlu'  contents  nmy 
!>«■  (Iiolesterin. 


Ki.i    1(17 


Kiii    108 


*'iiii.ii  ..f  I'Miiiiiiiin  tnixi'd  liiliniliin  falciii 
t:;illMtuni*.     IN'iiuiiyu.) 

Kiu.   IWI 


C'holri'.rin  cult  iilu»,  cut  tuid  rxilislied  lo  n  ,.\ 
rniliale  crysittllinc  .Hiriiiiiiri'.     (.\buii> 

Km.   170 


"MiriDrphoiia"   I'lioli-Micrin   K.-ilNtnup 
iiiK  r.  niral  rnvitaliiin.     (NaiiiiMi  ) 


Pure  hiliruliin  ..iliium  <-»Idili;  bile  (travel 
':  N'iiuuyn.) 


■'■  I'lnr  Hilinihin  Calrliim  ('(ilriili- Thvsv  are  sometimes  termed 
"bile  gravel,"  and  are  miiltii)le  hiaekish  >jrannles,  lying  in  mucoid 
li'l'  ;  Oiiii  fresh  they  are  soft,  and  break  under  the  finger;  when  drv 
tlifx  rniiiilile  apart. 

1  '  •ilriiim  ('(irhoimfr  rri/r(//i. -Comparatively  rare,  these  stones  are 
^»p  i ml:  more  often  nodules  of  calcium  carbonate  occur  in  the  mixed 
•'alciiii.  (ir  coininon  gallstones. 

Etio!)gy.  In  the  difficult  problem  of  determining  the  cau.ses  of 
;'|ill^'.  ■  , ..  there  are  certain  well-recognized  facts  at  the  outset,  such  as 
thfs,  i,;it  they  occur  most  often  in  or  after  middle  life,  in  females 
''"•■n.  Miiiii  males,  and  in  those  of  sedentary  rather  thai:  of  active 
nalMt-  .„!  that  the  cholesterin  of  which  they  are  formefl  i.s  not  excreted 
to  an;    .Attnt  by  the  liver,  but  from  the  mucous  membrane  of  the 


320 


THE  REGRESSIVE  TISSUE  CHANGES 


gall-hladder  and  the  bile  iJassaRos,  especially  the  former.  Tlie  increased 
production  of  ciiolcst«'rin  is  due  to  a  catarrhal  state  of  the  Kali-bladder 
wall,  induced  by  some  bacterial  aRcnt,  often  of  a  low  grade  of  virulence; 
the  readiness  with  which  the  gall-bladder  is  infected  in  general  blocKl 


Fio    171 


Fia.  172 


n 


Corpnrii  aniylaces  from  brain,  to  »lio»- 
hiniiiiHtnd  character.      X  SSI) 


Fui.   17.) 


S(M'li(jn  throujrh  an  amyloid  hody  from  a  eternal  tmimr, 
\ft  more  highly  ni!iKuifi<'d,  ti>  sliow  the  subcrjs'talline 
(If'pohit  of  yiu-c'ssivc  liner'*  of  rlowely  parked  needles  of 
aniyliiid  material.  At  a  the  needles  radiate  from  a  small 
foeiis.     (Ophiila) 


Fig.  17-1 


-"i^ 


n 


•  >%^ 


Aiiiyloid  liody  (rnrn  lung  (immersion  lens)  to  show 
radiate  crystalline  formation  similar  to  that  w'en  in 
figure  precedinft. 


Amyloid  body  lying  in  a  pulni' nnr>- 
alveolus  from  a  case  of  chronic  pi.^'ive 
congestion  of  the  lung  (high  power! :  o. 
large  "cardiac"  cells,  containing  pisnient; 
h,  ml  corpuscles. 


infections,  such  as  typhoid  fever,  will  be  recalled  in  this  coiincttion; 
finally  it  is  necessary  for  such  a  state  of  aflairs  that  the  bile  be  staunaiit, 
the  ci,utent>  of  tiiV  K"ll-f>laddcr  not  being  quickly  drained  <■•••!  as 
quickly  renewed. 


mkk 


o^mgm 


«B* 


PIGMENTATION  AND  PIGMENTARY  CHANGES 


321 


111  gallstones,  as  in  urinary  calculi,  is  a  mucinous  matrix  in  which  the 
Milts  arc  deposited,  and  such  mucinous  matrix,  here  also,  indicates  that 
for  their  production  there  must  be  a  catarrhal  condition  of  the  gall- 
Miiddcr,  with  increased  outpouring  of  mucus  into  the  bile.  The  studies 
(if  tlif  last  few  years  have  shown  us  with  increasing  emphasis  the  fre- 
(luciuy  with  which  organisms  of  low  virulence,  notably  the  B.  coli  and 
H.  typhosus,  exist  for  long  periods  in  the  gall-bladder.  It  has  been 
shown,  indeed,  that  cultures  of  one  or  other  of  these  organisms  added 
t(.  sterile  bile  leads  to  a  deposit  of  all  the  constituents  of  gallstones. 
'1  liiis,  both  by  favoring  a  low  form  of  catarrh  and  by  acting  on  the  bile, 
these,  and  other  organisms,  directly  lead  to  the  production  of  gallstones. 
As  to  the  cause  of  the  great  variation  in  the  relative  amounts  of  the 
(lillVrent  constituents  we  are  still  in  doubt,  but  pure  cholesterin  calculi 
art-  most  frequently  found  in  cases  in  which,  through  obstruction,  the 
pill-I)ladder  or  its  duct  are  cut  off  from  the  flow  of  liver  bile.  Their 
tlidlcsterin  appears  thus  to  be  derived  mainly  from  the  mucous  mem- 
hruiic  lining  the  gall-bladder  (and  ducts).  The  deposit  of  calcium  salts 
ai)i)(ars  to  be  associated  with  the  breaking  down  of  cellular  debris,  as 
in  other  concrements. 

Prostatic  Calculi.— Section  through  the  prostates  of  most  men  past 
niKldie  life  shows  the  presence  of  minute,  dark-colored  granules  in  the 
suhstance  of  the  organ;  these  are  sometimes  called  prostatic  sand. 
They  are  situated  within  the  lumina,  are  hyaline-looking,  generally 
polyf,'onal,  and  of  concentric  structure;  they  are  so  soft  as  to  be  capable 
of  eiitting,  and  give  imperfectly  the  reactions  of  amyloid;  they  are 
sometimes  called  amyloid  bodies  of  the  prostate,  and  one  of  them'  may 
l>e  the  nucleus  for  the  incrustation  of  salts. 

Corpora  Amylacea.— Closely  allied  to  the  last  are  minute  concretions 
toinid  in  the  brain  and  spinal  cord  of  the  old,  in  lung  alveoli  in  cases 
of  (lironic  congestion  with  hemorrhagic  discharge  into  the  alveoli, 
ami  ill  certain  tumors.  They  have  the  general  appearance  of  hyaline 
"iiattTal.  The  growth  of  some,  at  least,  of  these  bodies  in  the  lungs 
and  II  tumors  is  by  successive  deposit  of  layers  of  obscured  crystalline 
iiecllt  ^  of  protein  nature  (Figs.  172  and  174). 


croi, 

]ln-.. 
pi-l; 
is.  ,! 

exo, 
aiw,. 
>ii 

El 
and 


icir 

ill) 

r 


PIGMENTATION   AND   PIGMENTARY  CHANGES 

relative   unimportance  is  the  chief  excuse  that  exists    for 

the  pigment  changes  of  different  sorts  together,  because  the 
111  of  color  is  no  adequate  ground  of  relationship.  The 
s  eaii  be  divided  according  as  they  are:  (1)  endogenous,  that 
11'  direct  products  of  cell  metabolism  or  disintegration,  or  (2) 

s,  that  is,  are  colored  matters  foreign  to  the  organism  and 
I  from  without.    The  endogenous  we  may  further  divide  into 

■Mnn  and  its  derivatives,  and  (6)  other  metabolic  pigments, 
enous  Pigments.  -Abnormal  Pigmentation  Due  to  Hemoglobin 

Jerivatives.— It  will  be  remembered  that  hemoglobin  occurs 


;}22 


THK  RKdliKSSIVE  TISSUE  CflANGES 


i     ! 


in  a  solul)lo  form  in  thf  blood  corpuscles,  and  especially  in  the  portiil 
system  (including  the  si)leen)  is  disinte;jrated,  hy  the  liver  cells  espe- 
cially, with  discharge  into  the  hile  t)f  the  iron-free  portions  of  the 
pigment  as  hilirnhin  and  other  hile  i)igments.  The  urinary  pigment, 
urochrome,  is  prohaMy  also  derived  from  it. 

Exj)erimentally,  hy  many  chemicals,  l»y  foreign  blood  serums,  and 
other  agents,  such  as  thermal  changes,  the  red  corpuscles  can  he 
broken  nj)  and  the  hemoglobin  freed  into  the  serum,  whence  it  diffuses 
into  the  tissues  and  is  absorbed  by  v<..ious  cells.  In  diseased  states, 
es|)ecially  sepsis,  hemoglobin  imbibition  occurs,  the  heart  valves  ami  the 
surface  of  the  iiorta  showing  a  bright-red  color  from  absorpticm  of  the 
pignif  "t,  a  condition  to  be  distinguished  from  postmortem  change  of 
the  same  tissues;  in  sepsis  the  staining  is  partly  ante  mortem.  When 
the  pigment  is  set  free  in  the  blood  in  large  amount  it  may  quickly 
appear  in  the  urine,  unaltered  as  in  hemoglobinuria  or  modified  as  in 
methemoglobinuria,  in  the  latter  having  a  firm  combination  with  the 
oxygen  with  an  acid  reaction.  If  the  red  cells  are  destroyed  in  the 
tissues  or  serous  cavities,  the  pigment  before  its  discharge  may  undergo 
a  further  change  into  hematoidin  or  urobilin  and  be  excreted  as  such 
(urobilinoria). 

Paroxysmal  hemoglobinuria  is  marked  by  the  sudden  appearance  of 
hemoglobimiria  for  a  short  time,  after  whi -i^  again  the  urine  becomes 
limpid.  With  some  i)eople  exposure  to  jold  is  enough  to  excite  the 
state,  and  the  attacks  are  most  frequent  in  winter,  the  red  corpuscles 
ap|)earing  to  be  abnorniiilly  sensitive  to  temperature  changes. 

Modificil  Ilemixjlohin. — Where  there  is  jjrolonged  hemorrhage  or 
h)cali/,ed  hemorrhage  in  tissues,  we  are  ai)t  to  find  the  hemoglobin 
extensively  modified,  a  fact  which  is  graphically  shown  l)y  the  succes- 
sive changes  of  color  of  a  "black  eye;"  the  substances  eventually 
obtained  are  hematoidin,  hemosiderin,  and  hemofuscin.  Hematoidin  is 
identical  with  bilirubin,  and  is  red,  iron-free,  and  to  be  found  in  the 
central  part  of  a  large  hemorrhage.  It  is  crystalline,  in  which  it 
differs  from  hemosiderin,  which  is  always  found  in  the  form  of  amor- 
phous granules.  In  the  anemias,  and  diseases  where  there  is  extensive 
destruction  of  red  corpuscles,  hemosiderin  may  be  deposited  extensively 
in  the  liver,  as  hai)pens  also  in  the  condition  known  as  hemochromatosis; 
it  is  an  albuminate  of  iron  in  which  the  iron  is  relatively  loosely  com- 
bined, and  hemofuscin  probably  represents  a  yet  more  stable  conil)ina- 
tion  of  the  sanu'  sort. 

Pseudomelanosis.-  This  is  the  dark  greenish  to  black  colonition 
seen  post  mortem  in  the  liver,  the  spleen,  lud  the  stomach  wall,  when 
these  organs  ha\-c  lain  against  the  intestine,  sulphuretted  hydrogen  set 
free  therefrom  combining  with  the  more  or  less  mtxlified  derivatives  of 
hemoglobin  and  leading  to  the  dejjosit  of  suljjhide  of  iron.  Hematopor- 
phyrin  is  an  iron-free  derivative  of  hennitin  which  is  set  free  in  the  urine, 
c:-i)ccia!!y  after  the  use  of  certain  drugs  *<uch  ns  sulphonal,  whose  acid 
constituent  set  free  in  the  blood,  acts  upon  free  hemoglobin. 


IjJLjilM  J 


JAUNDICE 


323 


Jaundice;  Icterus.— The  pigment  of  the  coiistiiiitly  secreted  bile  is 
ilcrixtd  from  the  never-ceasing  destruction  of  red  corpuscles,  which 
iitttr  !i  short  existence  of  a  few  weeks  fade  away  in  the  iilood  stream 
(ir  .ire  jiicked  up  by  the  phagocytic  cells  of  the  spleen  and  liver,  their 
licriiDfilobin,  either  unaltered  or  modifie<l,  being  absorbed  by  the  endo- 
tliclimn  of  the  hepatic  capillaries,  and  by  them  passed  on  to  the  liver 
(rlls  to  be  broken  up.  The  iron-free  part  is  discharged  into  the  bile 
(ii|iill!irics  as  bilirubin,  the  pigment  of  <he  bile;  as  to  the  iron-contain- 
iii<;  part  of  the  hemoglobin,  it  is  evidently  jealously  preserved  by  the 
or^'itii,  for  very  little  passes  into  the  bile,  and  relatively  little  remains 
sKind  in  a  combined  state  in  the  liver.  Should  the  bile  pigment  fail 
to  lie  discharged  from  the  liver,  it  accumulates  and  regurgitates  into 
tlif  l)l()od  and  lymph  vessels,  and  is  carried  in  a  soluble  state  to  the 
ti>^ii<s  elsewhere,  in  which  it  is  dissolved,  causing  them  to  assume  a 
l)il(->iained  appearance.  This  staining  is  jaundice  or  icterus;  the  accom- 
panx  ing  symi)toms,  such  as  itching  of  the  skin,  slowing  of  the  pulse, 
mental  depression,  and  melancholy  (literally  black  bile)  are  entirely 
suliMdiary,  due  to  associated  absorption  of  bile  salts,  etc.  The  blood, 
the  urine,  and  the  tissues  show  the  chemical  reaction  for  bilirubin 
iir  the  inoro  highly  oxidized  biliverdin,  and  the  liver  is  the  first  organ 
t(i  ^Imiw  this  coloration. 

<  liiiically,  the  sclerotics  of  the  eye,  the  mucous  membrane  of  the 
iiioiitli,  and  the  hard  palate  show  pigmentation  early,  the  skin  quickly 
>lin\v-,  it  and  the  connective  tissues  throughout  the  body;  cartilage, 
till  n.riiea,  and  in  general,  the  nervous  tissues  (save  in  infants)  are 
nlaiiuly  unaffecte«l;  the  secretions,  the  urine,  the  sweat,  the  saliva 
-iiou  it;  tlic  milk  more  rarely,  and  the  tears  (it  is  s.,;d)  never;  the  pale 
(iilor  nf  till-  feces  indicates  that  little,  if  any,  is  discharged  from  the 
i:\i\u<U  (.r  the  stomach  and  intestines.  The  skin  may  show  any  grada- 
tion lictwcen  pale  yellow  and  deep  olive  green,  and  the  disappearance 
of  till-  color  is  usually   ir.-v. 

/,/"./„<///.    -It   sf-  if   true  jaundice   were   always  obstructive 

in  ninirc,  with  i  vtion  of  pigment  into  the  circulation.  In 
nlitnirtivo  jaundi  ,.  -perly  so-called,  it  is  obviously  so,  for  there 
is  .M!  ol.>tru<tion  i  i  .  bile  channel  somewhere  between  the  hepatic 
Mnd  the  papilla  in  the  duodenum;  there  may  be  congenital 
ni-;  or  absence  of  the  main  ducts,  inflammatory  swelling  of  the 
Htli  narrowing  of  the  lumen  (catarrhal  jaurwUce),  growths  or 
I  lioilics  within  the  passage,  new  growths  outside  the  passage, 
u  iiiton  it,  or  perhaps  even  a  spasmcnlic  s'ricture  of  the  duct. 
■  '•■}■  of  these  the  bile  chainiels  are  distended,  and  it  is  found  that 
l>  the  pigment  injects  a  fine  intracellular  network  of  channels, 
lU  with  the  bile  capillaries.  This  network  surrounds  the 
t  the  cell  but  does  not  enter  it,  and  if  distended,  throws  back 
!|H>n  the  cell,  where  it  is  at  once  absorbed  by  the  lymphatics; 
'1'-^  less  rapidly,  but  surely,  the  pigment  makes  its  way  into  the 
'  !o(m|;  the  latter  process  is  much  hastened  if  rupture  of  bile 


IoIih! 

niirri 

Willi 

for. 

prr- 

Wii!. 

nltiii 

I'oni- 

niir!. 

thr  ! 

aii<i 

hrpir 


324 


THE  RECRFISSIVE  TISSUE  CHANGES 


ducts  should  occur.  A  second  way  in  which  jaundice  can  be  caused 
is  by  the  breaking  down  of  a  large  number  of  red  corpuscles  in  the 
circulation;  the  liver  cells,  presumably  overloadetl,  excrete  a  concen- 
trated, inspissated  bile  by  which  the  fine  channels  are  blocked;  the 
obstruction  is  not  complete,  the  feces  may  remain  colored,  and  the 
jaundice  may  not  be  very  severe;  such  a  form  of  jaundice  may  occur 
in  sepsis,  and  is  evidently  hemohepatogenous  in  its  nature.  Yet  another 
kind  of  jaundice  is  found  in  such  states  as  acute  yellow  atrophy  of 
the  liver,  in  phosphorus  poisoning,  and  in  the  infective  jaundice  of 
children  where  the  pigment  is  evidently  freed  from  liver  cells  during 
their  destruction;  it  must  be  remembered,  in  fact,  that  whenever  many 
liver  cells  are  destroyed  at  the  same  time  jaundice  may  supervene. 
Finally,  severe  shock  or  nervous  disturbance  has  been  followed  by 
jaundice,  a  phenomenon  which  we  are  not  able  to  explain. 

Urobilin  Pigmentation.— A  true  hematogenous  pigmentation  of  the 
tissues  by  urobilin  can  occur,  the  pigment  being  supplied  from  hemo- 
lysis in  the  vessels,  without  direct  participation  of  the  liver;  this 
is  not  jaundice  proper,  although  any  corsiderable  degree  of  hemo- 
lysis is  likely  to  Itad  quickly  to  that  stat^.  The  lemon-yellow  tinge 
of  the  skin  in  gr;i\e  anemia  and  the  paler  color  of  cancerous  cachexia, 
as  well  as  the  dis<  '>ioravli,ii  of  the  skin  in  hemochromatosis  appear  to 
be  of  this  order. 

Other  Endogenous  Pigyiientations.—'Sa.ela.notic  Pigmentation.-  Of  the 
autochthonous  pigments  not  derived  from  hcinoglobin,  the  most 
important  are  the  melanins,  bodies  poor  in  iron  but  rich  in  sulphur, 
which  exist  normally  in  the  choroid  of  the  eye,  in  the  Malpighian 
layer  of  the  skin,  in  the  hair,  and  in  the  membranes  of  the  brain,  and 
are  lacking  in  so-called  All)in()s.  Increases  of  pigmentation  are  seen  in 
pregnancy,  in  exophthalmic  goitre,  in  certain  neurotic  states  (melasma), 
in  Addison's  disease,  and  in  melanotic  tumors.  This  deposit  of  melanin 
appears  to  be  due  to  a  process  in  which  oxidases  act  upon  the  chrom- 
ogen  grouj)  of  the  protein  molecule,  with  the  pnxluction  of  pigmented 
substances  allied  to  tyrosin  and  the  mem)»ers  of  the  aromatic  series  of 
protein  dissociation  i)roducts;  these  fail  to  undergo  lurther  conversion 
and  so  accumulate  in  the  tissues. 

Llpochromes.-  These  are  colored  fatty  bodies,  which  give  color  to 
the  fat,  to  the  corpora  lutea,  to  xanthomas  and  chloromas,  and  under 
certain  conditions,  to  the  cells  of  the  nervous  system.  Present  indica- 
tions are  that  they  are  fats  combined  with  ty rosin-like  bodies. 

Exogenous  Pigmentations.— These  consist  of  colored  substances 
absorbed  by  and  deixisited  in  the  tissues,  or  colored  derivativis  of 
substances  not  themselves  colored.  Tattooing  is  a  familiar  exnp;|)ie 
of  the  first  of  these,  where  insoluble  j)articles  of  vermilion  or  another 
pigment  are  rubbed  into  fine  punctures  in  the  skin;  the  particles,  I'lose 
at  least  which  are  not  carried  away  to  the  nearest  lymph  ntnles,  vvvM\n 
in  the  outer  layer  of  the  corium,  whence  some  of  them  are  graiii  aii.v 
removed,  producing  a  fatling  of  the  color.    A  superficial  inflamin mm 


iiiH^^-SKHMfHi 


!*?■ 


EXOGENOUS  PIGMENTATIONS 


325 


lasting  some  time  may  almost  obliterate  the  tattoo  mark,  because 
Icukdcytes  are  called  to  the  part  and  engulf  particles  of  pigmer  t.  More 
important  are  the  pigmentary  deposits  in  the  lungs  from  inhalation, 
the  pneumonokonioses  (from  /''wc,  dust).  The  commonest  of  these  is 
anthracosis,  the  deposit  of  coal  dust  found  in  the  lungs  of  city  dwellers 
and  coal  miners;  these  dei>osits  are  black,  whereas  rather  gray  in  color 
are  tlie  deposits  of  siliceous  particles  in  the  lungs  of  quarrymen,  stone- 
cutters, and  workers  in  „.anite  (chalicosis — X'^^'^<  a  pebble — or 
silicosis).  The  lungs  of  knife-grinders,  glass-polishers,  and  others 
working  with  iron  or  iron-oxide  dust 
lu'come  a  rusty  red  (siderosis) ;  those  f'o  i76 

of  pottery  workers  show  dirty-white 
deposits  in  the  lungs  (aluminosis), 
and  those  of  workers  in  tobacco  dust 
a  rusty-brown  deposit  (tabacosis). 
Dust  j)articles  in  the  air  May  not 
all  lie  entangled  by  the  moist  wall 
of  tlie  nasal  cavity,  the  pharynx 
and  the  trachea,  but  some  reach  the 
pulmonary  alveoli,  where,  lying  upon 
the  e[)ithelium,  they  are  picked  up 
by  wandering  leukocytes,  which,  in 
turn,  if  not  discharged  in  the  sputum, 
make  tiieir  way  back  into  the  lymph 
stream;  once  there,  they  may  dis- 
integrate and  leave  their  pigment  to 
the  endothelial  cells  or  they  may 
("irr.\  it  to  the  nearest  lymph  node. 
'I'his  explains  the  deposit  so  abun- 
dantly present  in  the  lymph  nodes 
of  the  respiratory  tract  of  a  city  dweller;  but  it  is  well  to  remember 
that  a  node  that  appears  absolutely  black  to  the  naked  eye  may  under 
the  microscope  prove  to  be  a  fairly  normal  structure,  the  pigment  being 
M  t  ti  in  scattered  masses.  Wherever  such  insoluble  particles  find  lodge- 
uii  lit  they  act  as  mild  irritants,  giving  rise  to  a  devek)pment  of  new 
(niiiitctive  tissue  in  their  neighborhood,  which  may  be  so  localized 
ariiiiid  a  large  collection  as  to  appear  like  a  tubercle;  a  lung  so  affected 
nil  infrecpiently  falls  a  victim  to  actual  tuberculosis. 

I  'i  ( lian>;es  induced  by  bodies  that  enter  the  system  in  a  colorless  form 
iiii'i  ;^i\c  rise  to  a  colored  deposit,  the  best  examples  are  the  "blue  line" 
"t  !  ;id  poisoning  and  the  deposit  of  silver  in  the  tissues,  known  as 
argyria.  The  "blue  line"  is  due  to  a  deposit  of  lead  j  'phide  in  the  gums 
at  a  ed^is  of  the  teeth,  which  is  a  result  of  the  combination  of  the 
'^i !  !i  suit  of  lead,  circulating  in  the  blood  and  lymph,  with  hydrogen 
sii!;  1  jc  jriven  off  from  the  decaying  food  material  lodged  in  the  inter- 
s' i  '■  It  ween  tb<.'  teeth  and  the  gums.  When  soluble  salts  of  silver  are 
p!  '  in  the  body  fluids  they  become  reduced  and  metallic  silver  is 
d'       !i  (I  in  the  tissues,  especially  the  connective  tissues. 


From  section  of  an  luithracotio  lung  to  ahow 
fibrous  areas  eocloaing  deposita  formed  of  fine 
coal  d'jBt  particles  (high  power). 


■■IMFIt-UB  1  JJ 


«IMiJ,J«iJ    J 


32G 


THE  REGRESSIVE  TISSUE  ClI.WdES 


NECROSES 


:i-i;    ' 


r 


Necrosis  is  death  of  cells,  of  tissues,  or  of  parts  composed  of  many 
tissues,  in  spite  of  which  «lcath  the  organism  as  a  wholt  continues  to 
live. 

Causation.~It  has  already  been  shown  that  there  are  many  grai.ii- 
tions  of  cell  disturhance,  in  some  of  which  quick  death  of  cells  or  tissues 
occurs  (necrosis)  while  in  others  the  cells  undergo  a  slow  degeneration 
whi'  erminates  in  death  (necrobiosis,  bionecrosis).  Those  forms  of 
nee  .  s  and  necrobiosis  which  occur  as  a  result  of  degenerative  change 
induced  in  the  cell  have  been  dealt  with,  but  there  remain  those  con- 
ditions of  necrosis  set  up  by  circulatory  and  nervous  disturbances. 

Circulatory  Disturbances. — Necrosis  is  induced,  on  the  one  hand, 
by  arrest  of  the  bloo<l  supply,  and,  on  the  other,  by  deficient  or  per- 
verted quality  of  the  blood  with,  as  a  result,  deficient  nutrition.  In 
a  general  way,  it  may  be  said  that  occlusion  of  the  afferent  artery  and 
occlusion  of  the  etterent  vein  of  an  organ  alike  produce  death  of  that 
organ;  in  both  cases  there  is  a  lack  of  oxidation  of  the  tissues,  death 
occurring  in  those  cases  in  which  there  is  a  relatively  poor  collateral 
circulation.  Necrosis  will  be  caused,  for  example,  by  ligation  of  an 
afferent  artery  or  efferent  vein;  pressure  on  the  vessel  by  tumors, 
cysts,  etc.;  thrombosis,  the  coagulation  of  the  blood  within  a  vessel; 
embolism,  the  blocking  of  a  vessel  by  a  foreign  btnly  in  the  wide  sense 
of  that  term;  the  constricting  action  of  a  drug  like  ergot  or  disease 
of  the  artery  wall  with  proliferation  of  the  intima  inducing  a  partiul 
or  total  occlusion.  If  the  agent  be  ai)plied  suddenly,  necrosis  follows, 
if  gradually,  necrobiosis. 

Inadequate  Nutrition.  —  (leneral  mahuitrition,  tending  to  a  weak 
heart  action  and  an  inadequate  blood  sujiply,  leads  to  a  progressive 
state  of  necrobiosis,  to  which  the  difi'erent  orders  of  tissues  res|)ond 
differently,  the  specialized  tissues  l)eing  more  readily  influenced  tlian 
the  lowly  connective  tissue. 

Nervous  Disturbances.  Two  questions  here  arise:  can  stimuli  from 
the  central  nervous  system  set  up  necrosis  (which  is  to  be  answered 
in  the  affirmative)?  and  can  the  loss  of  nerve  supply  lead  to  a  like 
result  (which  is  to  be  met  by  a  qualified  negation)?  Cer.tral  stiirnili 
can  apparently  affect  the  vasomotor  system  so  that  constriction  of 
the  vessels  may  be  followed  by  local  anemia  and  even  by  necrosis  as 
in  Raynaud's  disease  (symmetrical  gangrene);  the  loss  of  nerve  sujjply 
may  lead  to  cell  inanition,  but  can  only  predispose  to  necrosis.  A  jiood 
example  of  this  is  seen  in  the  supposition  onee  widely  held,  that  section 
of  the  fifth  nerve  led  to  ulceration  of  the  cornea,  and  that  neurotrophic 
keratitis  was  a  definite  entity;  but  we  now  know  that  if  in  these  cir- 
cumstances, the  cornea  be  protecte*!  from  light,  dust,  and  injury,  no 
keratitis  occurs.  Nevertheless,  true  though  it  is  that  nerve  loss  is  mtTcly 
a  predisposing  factor,  it  is  to  be  admitted  that  inanition  atrophy  iin<l 


Ai»»m- 


]L'ilfJ 


(•swn^sv-^IVVBMil 


NECROSES 


327 


^  a  I'lal  death  of  cells  will  follow  upon  loss  of  nerve  connection  with 
its   (insequent  inactivity. 

FiQ.  170 


W  ,\  like  <legcncralion  of  iimscle  fibres  (a.  h)  scvtntccn  hours  uflor  tciniHirary  lisation  of  the  same. 
In  '»  there  is  -Iroady  aome  uccutuulation  of  h-uk'-'-j  tt-t*.     (t  >lMTnd6rfTer.) 


Fia.  177 


M       ; :!i'  focal  necrosps  in  the  liver  of  a  rabbit  subjected  ti,  experimental  glamlers.     (Duval.) 

For    T   of   Necrosis. — Distinction,   partly   clinical,    may   be   made 
bttw  .     cliHVrcnt  forms  of  necrosis;  there  arc  (1)  necroses  of  individual 


328 


THE  REGRESSIVE  TISSUE  CUANGES 


cells;  (2)  those  affecting  small  groups  of  cells,  focal  necroses;  (.3)  those 
uffecting  circmiiscribiHl  areas,  as  a  result  of  vascular  obstnu  tion 
infurcts,  and  (4)  necrosis  affecting  parts  rather  than  tissues — guigrene. 

1.  Necrosis  of  Individual  Cells.  In  adtlition  to  the  degenerat-ve 
changes  alieady  dealt  with,  there  is  the  waxy  degeneration,  known 
as  Zenker's  defeneration  of  muscle,  seen  es|)ecially  well  in  the  recti 
muscle?  the  abdomen  in  typhoid  fever,  in  muscles  after  trauma, 
and  at  ...-..^s  in  the  heart  muscle.  The  fibres  lose  their  striation  and 
become  waxy  or  glassy  in  appearance,  the  sarcolemma  still  intact. 
It  appears  to  be  a  coagulation  of  the  muscle  substance,  the  myosinogen 
becoming  converted  into  myosin. 

2.  Focal  Necroses. — In  cases  of  se\ere  infections  there  occur,  in 
various  tissues,  minute  areas  of  necrosis  scarcely  visible  to  the  naked 
eye;  such  are  seen  in  the  lymph  follicles  in  diphtheria  and  typhoid 
fever;  in  the  liver  in  typhoid  fever  and  other  forms  of  sepsis,  even 
chronic  forms,  and  most  marked  of  all  in  the  liver  in  eclampsia. 

The  causation  of  these  focal  necroses  is  yet  unsettled;  there  is  con- 
siderable evidence  in  favor  of  thrombi,  sometimes  hyaline,  which  may 
be  formed  by  hemolysis  of  red  cells,  or  by  alteration  of  capillary  endo- 
thelium which  has  been  killed  by  toxins  and  cast  off  into  the  lumen. 

Fat  Necrosis.— Of  quite  a  different  causation  are  the  necroses  which 
occur  when  the  fat-splitting  ferment  present  in  the  pancreatic  secre- 
tion comes  in  contact  with  unproteded  tissues.  These  are  opaque, 
whitish-yellow  islands  of  small  size,  seen  in  the  fatty  tissues,  generally 
in  the  vicinity  of  the  pancreas;  any  circumstance  which  allows  the 
pancreatic  secretion  to  act  upon  tissues  other  than  the  pancreas  or 
the  intestinal  wall,  may  lead  to  their  formation. 

3.  Infarcts  and  Ck)agulation  Necrosis. — The  produ(  on  of  infarcts 
will  be  more  fully  considered  later,  but  it  is  needful  »  mention  here 
coagulatit)!!  necrosis,  a  process  best  seen  in  infarcts  ol  the  kidney  and 
spleen.  In  addition  to  the  death  of  the  cells,  there  is  a  fibrinous 
coagulation  of  the  whole  area,  fibrin  being  demonstrable;  besides 
this,  the  dim  outlines  of  the  tissues  of  the  part,  dead  and  without 
nuclei,  can  be  seen.  The  blood  fibrin  is  one  of  a  group  of  coagulahle 
proteins,  and  this  process  is  evidently  comparable  to  that  which  obtains 
in  Zenker's  degeneration,  where  myosinogen  is  converted  into  ccjagu- 
lated  myosin.  Closely  allied  to  this  is  colliquative  necrosis,  in  which 
there  is  liquefaction  of  the  dead  tissue  as  a  process  of  self-digestion 
or  autolysis,  not  to  be  confounded  with  putrefactive  necrosis,  wliere 
the  liquefaction  is  the  result  of  proteolytic  powers  of  bacteria,  'i'iie 
for-ner  is  seen  in  infarcts  of  the  brain  and  in  the  centres  of  tumors  iind 
large  thrombi,  especially  in  the  parietal  thrombi  of  the  heart  cavities. 

4.  Oangrene  and  Mortification. — ^The  death  of  large  areas  mav  lie 
brought  about  by  many  agents — by  vascular  obstruction,  by  a(  iite 
infection,  by  burns,  frost-bite,  corrosives,  and  physical  forces  such  as 
radium,  the  x-rays,  and  electricity.  The  results  of  such  necrosis  \  iry 
widely.    Where  the  necrosed  area  is  small,  and  not  infecte<l  (1)  absorp- 


J.y» 


Pi^l 


NECROSES 


329 


tion  occurs.     By  autolysis  and  the  uctivity  of  leukocytes  the  dead 
part  may  I      removed  and  its  place  taken  by  regenerated  tissue  of 


Fio.  178 


1'  infarct  uf  cortex  of  kidney  to  show  coagulation  necrosis,  with  surrounding  tone  of  congestion: 
o.  artery.     (Orth ) 


Fia.  179 


Fn., 
c,  coil; 


niia  of  an  adrenal  gland,  to  show  the  gradations  in  cell  damage  leading  to  coagulation 
Ircniil  cells  still  retaining  nuclear  stain;  b,  the  same  with  fading  of  nuclear  chromatin; 
necroeed  cells  seen  as  fused  shadows^  d,  blood  corpusoles. 


330 


THE  REORKSSIVK  TISSUE  fll.WdES 


the  part.  More  often,  esiHTially  in  areas  of  lurjjer  size,  (2)  cicatriiation 
occurs;  surroiiiuliiin  tlie  (lead  area  is  a  zone  of  reactive  iiitiniiimatii)ii 
inductnl  hy  the  presence  of  the  «leatl  tissue  and  tlie  ditVused-out  pro<l- 
ucts  of  its  disinte),'rati(>:i;  from  tliis  zone  a  formation  of  K^uHulution 
tissue  and  vascularization  of  the  same  arises.  In  some  areas,  as  in  the 
brain,  where  reparative  process  is  comparatively  sh)w  hy  reason  of 
the  rehitively  small  amount  of  supiM)rtive  tissue,  and  where  colliqua- 
tive necrosis  is  i)roi\e  to  occur,  instea«l  of  a  solid  cicatrization,  there 
is  likely  to  he  (li)  cyst  fonnbtion.  In  tissues  such  as  lM)ne  that  are  so 
dense  that  (!isintegration  of  dead  matter  is  a  long-<lrawn-out  process, 
the  surface  portions  of  the  dead  area  may  he  disiutegrate<l  and  l(H)sene(l 
from  the  surrounding  tissues,  and  the  central  mass,  not  yet  disinte- 
j;rate«l,  may  remain  as  (4)  a  sequestnun,  lying  in  u  cavity  and  Imthed 
hy  purulent  flui<l.  Another  scfjuel  to  colliquative  chanRe  is  (a)  iaspiua- 
tion,  in  which  the  fluid  part  of  the  dead  nuiterial  drains  away,  leaving 
a  gradually  thickening  residue,  which.  In-coming  cheesy  in  consistence, 
is  prone  to  he  a  seat  of  calcareous  dejwsit. 

Coming  to  the  consideration  of  gangrene,  according  to  the  amount  of 
hl(K)d  entering  the  dead  area  and  the  rate  of  evaiwiration  of  fluid  from 
the  surface,  occurs  (t>)  moist  fUKrene  or  sphacelus,  or  (7)  dry  Kangrene 
or  mummificatioii.  In  moist  gangrene,  a.s  in  the  lung,  intestine,  or  an 
extremity,  hlood  enters  the  part  and  evaporation  is  preventetl,  the  dead 
tissue  becomes  waterlogged,  and  l)y  the  entrance  of  various  microl)es 
l)utrefaction  sets  in;  the  aflfectwl  tissue  is  swollen  and  livid;  on  the  skin 
large  blebs  form  filled  with  fluid;  the  discharge  is  foul  from  bacterial 
growth,  and  the  soft  tissues  gradually  become  decomposed  and  liquefy, 
the  bony  jjortion  being  the  last  to  yield.  Dry  gangrene  may  occur  in 
the  extremities  and  the  ears,  the  necrotic  iM)rtion  becoming  shrunken, 
wrinkled,  and  dark  brownish  black  in  color,  like  mummy  flesh.  .\t 
the  boundary  between  the  living  anil  the  dead  tissue,  a  zone  of  intense 
inflanunation  develops,  the  line  of  demarcation,  at  which,  by  leukocytic 
and  cytolytic  activity,  a  .separation  and  ultimately  a  detachment  nuiy 
be  made. 

DEATH 

Why  does  the  body  die?  Apart  from  any  jjhilosophic  pronouncenniits 
we  call  find  some  definite  knowledge  on  the  subject.  Death  is  not  an 
inherent  (piality  of  living  matter;  ilic  schizomycete— and  this  is  true  of 
all  protozoa— within  certain  limits  of  heat  and  cold,  moisture  aiui  dry- 
ness, grows,  divides,  and  adapts  itself  to  change  over  long  ix-riods  of 
time;  accidental  death  ma.,  supervene,  by  desiccation,  by  physical  and 
chemical  means,  but  in  the  processes  of  such  life  there  is  no  suggestion 
of  death.  In  the  hematozoon  of  malaria,  its  disappearance  is  not 
death,  but  a  division  into  many  new  living  individuals,  and  all  of  the 
original  body  save  some  parai)lHsmic  pigment  appears  to  enter  into 
the  new  individuals.  With  the  multicellular  organism,  death  appiars; 
the  germ  cells  alone  carry  on  the  continuity  and  the  somatic  or  Ixxiy 


mrmn 


DEATH 


331 


((■ll>  (lie.  Ill  tlio  jierni  <«'lls  ilt'iith  is  iH)t  inherent;  in  the  somatic  cells 
liKiiiiM-  of  their  s|M>ciaii/iition  of  function,  death  becomes  inherent. 

II  ii  nitilticelhihtr  organism  or  a  cell  republic  could  \h'  inuiKineil  in 
wliidi  all  cells  arrived  at  maturity  sinmltaneousl\ ,  and  in  which  each 
((II  (diitributed  exactly  to  the  needs  of  others,  there  would  be  no  need 
for  -.(iinatic  death.  IJut  such  an  individual  d«K's  not  exist;  different 
(iriltr>  of  cells  are  required  to  be  mature  and  active  at  different  times. 

III  I  lie  case  of  man,  there  are  develoi)ed  in  the  enibryo,  organs,  such 
IIS  tlic  yolk  sac,  which  are  merely  of  temiM)rary  use.  When  their  pur- 
]i(>M'  is  accom|)lished  they  atrophy  and  disappear,  and  their  place  is 
tiikiii  by  other  «irpins  and  a  new  cellular  e(iuilil>riuin  has  to  l)e  c.tal)- 
li^licd.  The  heart  and  kidneys  Iwconie  functional  early;  the  jjenitaliu 
n  liitivtiy  late,  and  the  latter,  too,  cease  their  functional  activity  In-fore 
tli(  iir<;anism  in  );eneral.  In  the  cases  in  which  orpins  sup])ly  internal 
N((  ret  ions  to  the  bloo«l  an<l  to  other  orjjans,  the  disa|)]H*arance  «>f  those 
(irf;aii>  lcu\  cs  the  I»Io<h1  and  those  tissues  impoverished  in  one  or  another 
(lircc  tioii;  if  the  function  of  the  tissues  that  have  «lisappeared  be  assumed 
\i(;iri(iiisly  by  other  tissues,  these  latter  have  their  reserve  of  force 
(1(1  HiiM'd  thereby.  By  such  constant  modification  there  is  increasing 
>tr(^N  tiirown  upon  the  remaining  cells  until  ultimately  somatic  death 
(if  tlif  ti>sucs  in  general  is  brought  about  by  the  failure  of  one  or  other 
ti^>iic  that  is  absolutely  indi>pensable  to  life. 

In  tilt-  interaction  of  tissues,  the  circulatory,  the  res|)irat()ry,  and 
tiif  iMT\()us  systems  are  indispensable,  and  cessation  of  the  activity 
(il  :niy  out'  of  tii.  m  will  bring  about  somatic  ih-ath;  organs,  too,  at  first 
^ifilit  insignificant,  such  as  adrenals  or  parathyroids,  have  been  proved 
t"  lie  (if  |)rinie  importance.  With  so  many  organs,  essential  to  life, 
it  i>  I  Icar  that  there  may  be  many  different  ways  in  which  somatic 
(Iciitli  Mi.iy  supervene,  because  the  exhaustion  of  one  single  system  or 
iirmm  will  be  enough  to  permit  somatic  death  to  occur.  Somatic  death, 
win  II  it  lilies  occur,  is  a  ces.sation  of  functictn  of  these  three  vital  systems, 
fnlliiw,  il  i)\  the  disintegration  and  decomposition  of  the  body  in  general, 
till Tt  iKit  necessarily  being  imnuHliate  death  of  individual  cells.  Signs 
(it  tlii>  somatic  death  are  the  cessation  of  respiration,  and  of  the  heart 
litiu. '  iDiidiiijrof  tlu"  cornea,  the  development  of  rigor  mortis,  and,  finally, 
iif  :;rt  ilcconiposition  and  putrefaction.  Rigor  '■s"  *is  is  due  to  coagu- 
liitiiii  iif  niyosiiiogeii  forming  myosin,  the  ci>agni..iion  being  brought 
iilmu;  li\  the  lactic  acid  of  the  muscle;  the  i)assing  off  of  rigor  mortis 
I''  ilm  III  aiitolytic  change;  its  onset  is  rapid  in  those  engaged  in  violent 
iiiii-.ii'ar  clldrt  at  the  moment  of  death  ami  in  cases  of  tetanus  or 
striliiiic  poisoning;  whereas  in  cases  widi  prolonged  wasting  or  of 
itspii  \i,i  (ir  litinorrhage  it  may  be  delayed  for  a  c>onsiderable  peri(Kl. 
llii'  I  iM  1.  too,  -A'  decomposition  is  variai)lo  in  time  according  to  tem- 
IMTaiix  ,  the  '.i  .rmally  moist  parts  such  as  the  intestine  show  the 
••Isani..  .;!!!ckly;  tiic  IxMlit's  of  those  dead  of  acute  infection  and  of 
I'iiiiiii  iiiia  cliangf  rapidly  not  only  because  the  bacteria  are  present 
jmt  a!  '.I  cause  the  jjrotective  substances  that  inhibit  bacterial  growth 
liivi  )     1,  cxliansted. 


1 ,1- 


1  I 
•'■I 


mss/i 


s|»K(iAL  ANT)  SVSTFMIC  I  VTHOIAXJY 

CilA/TEii      'I 


IHE  CARl»IO\    ^CULAli    SYS' 


n 


K'liM  tlu'  discussi'  "  of  the    r<M 
ilii  (.11  and  tlie  tissui      we  'ir 

iiiitl  -ystfiiis;  puss,  tli;      i- 
kiiiiwii  as  (leiuTiil  Pat!      >ir>  lu  tlr 
it    Systemic  I'litholij;.        Our 
!mi-.  'lie  i.uiiiliar    •  ith  I       ^ari>        ; 
or       .  lint,     alizfi-'  always  ths^i  pa^ho 
iii.M..iii«',  to  kt'fi)  .        ind  b<      ihest  iesi 
ill.  iMiicnuii  of  tin       st(        .'    which  th 
iiiimIun  iIu-  nctiviti'  -  "C  ''      'hhIv  as  « 
\aliicto!'.    pnH'titi<  !UT  II.  for 

I  ;i-f  "if  iv\..i)l»thaiii»ic  ^  litrt-  to  hi     ' 
;!i\ri>iil  el  .'njtes  tlmt  tu'cur  in  ti 
I  ii(oii>]'     ippreti  ttes  what  the 

tv  ttif    ti,\Toi(i  Us,    il'   Tt 

creaM!  oxidati 


d  tff«ft- 

•fd  to  ■■ 
cons'i' 

.,1  Spe 


ke  im. 
•on 

>r,  ■• 


III 
.<-  orj{ 
..^  usua. 
;  prefer  to  ten. 


■  lid  si< 

iain  ! 
ral     'li. 
■!  i  he 

.r  pai       ' 

"  a  Mh 
lufori 
,je<-t. 
!   -tudy 
'liat  oft! 


'  I 


.1. 


iogist     IS  not  merely  tfi 

it  nia\-  affect  each  special 

the  handmaid  of  clinical 

s  t>i  particular  organs  mo<lify 

•  orpans  form  a  part,  and  so 

lie.    It  is  of  pccuiiarl ,    little 

»le.  he  has  diagnosticated  a 

lit    mind  the  picture  of  the 

,tse,  I       >s  with  this  he  simul- 

iges  ii   !)ly,  namely,  increased 

■  d  disclnrge  into  the  hl<HMl  of 

changes,  and  metabolic  activity 

\ise  of  pathology,  in  short,  is  to 

I  oi     isease,  and  with  this  to  afford  indications 

lUiu.,    and      iile  the  mass  of  data  with  which  the  student 

iliar  is  -    '  irgc  t'  at  oil-  treatment  of  systemic  ....  liology 

il!      ph  anized        very  thing  is  to  be  l;rought  wiuiin  the 

Ji        lume,  V    -      1'        ;ghout  conscientiously  endeavor 

ir  readers  th  'r  and  more  practical  aspect  of 


:!; 


the  pathology  of  tin'  cardiovascular  system  includes, 

irculation  medium,  theJ)lood  (and  lymph),  and,  second, 

.atus  whereby  this  medium  circulates. 

•d  we  must  cimsidcr  the  lymph     That  also  circulates. 

.  to  s,-iy  in  a  poll-parn.t  manner,  that  all  the  tissues  gain 

incnt  fr(>m  the  1)1o<k1,  am'  saying  this  to  forget  that,  save 

f  leukocytes,  which  are  suspended  in  the  blood,  and  those 


f 


;j34 


THE  CAHDIOVASCCLAK  SYSTEM 


otIuT  cells  wiiicli  line  tlu-  hloodvcsscis,  this  staTcment  is  incorrect,  KiviiiR 
us  a  false  mental  picture  (if  what  really  happens.  Save  in  the  case  of 
the  above-mentioned  exceptions,  the  tissue  cells  j;ain  their  nourishment 
from  the  lymph.  This,  it  is  true,  is  derived  fro-n  tiie  hlood.  It  is,  how- 
ever, m)t  identical  with  the  hlood  plasma;  its  comiM)sition  varies  in 
different  organs  and  rej;ions  and  in  diHVrent  states  of  the  body;  the 
indications  are  that  its  transfusion  from  the  vessels  is  larijely  a  governe.l 
process,  varying  according;  to  circumstances,  while  it  receives  i)rimarily 
those  pnxlucts  of  c«'II  activity  which  are  not  directly  excreted  by  the 
glands.  The  lymph,  then,  rather  than  the  bloo<l.  is  "the  great  medium 
of  interchange,  and  as  such  must  not  be  passed  over,  as  we  imagine  is 
the  tend«-ncy,  as  of  secondary  importance. 

Saying  this,  we  admit  that  just  as  the  lymph  originally  is  derived 
from  the  blood  so  sooner  or  later  it  is  discharged  into  it  again. 
We  have  to  deal  with: 
I.  The  blood. 

1.  Quantitative  alterations: 

(i)   In  the  amount  of  blood  as  a  whole. 
(2)  In  the  amount  supplied  to  particular  regions. 
(.'})  Disturbances  in  blood  sujjply  brought  about  by: 
(a)  Hemorrhage. 

(h)  Intravascular  disorganization  of  the  l)lood  (throm- 
bosis). 
(c)  KHVcts  of  foreign  bodies  (embolism). 
2.  Qualitative  alterations: 

(1)  In  the  fluid  menstruum  of  the  blood. 

(2)  In  the  corpuscular  elements. 

II.  The  lymph. 

1.  Quantitative  changes; 

2.  Qualitative  changes. 

III.  The  blood-forming  organs. 

It  will,  however,  be  more  con\enient,  as  it  is  more  in  accordance 
with  cust(»m,  to  discuss  the  blood-forming  firgans  after  we  have  treated 
the  cardiovascular  apparatus. 


Eli  1 


THE  BLOOD 

Quantitative  Alteration.-  It  needs  l)ut  a  short  experience  in  the  jiost- 
niortem  room  to  realize  that  in  disease  the  relative  amount  of  blood  in 
the  body  varies  within  very  wide  limits.  Some  bodies  are  strikingly  dry, 
others  'notably  cases  of  chronic  obstructive  heart  disease)  ooze  abundant 
blood  at  every  cut.  But  in  health  also  there  is  wide  variation.  Tiiis  is 
demonstrated  by  Ilaldane  and  J,orrain  Smith's  method.  Carbon  mon- 
oxide is  taken  up  by  the  red  corpuscles  with  much  greater  avidity  thnii  is 
oxygen.  If,  therefore,  an  individual  be  made  to  breathe  fora  short  time 
a  known  amount  of  carbon  monoxide,  it  is  easy,  l)y  removing  after  ii  lew 
minutes  some  cubic  centimeters  of  that  individual's  blood,  to  e.stimate 


wiyM 


THE  BLOOD 


335 


tluimioiint  of  carhon  motioxide  per  ciifnt-  centimeter  in  that  blood,  and 
tlu  r.tore  the  total  nnmherof  cubic  centimeters  of  the  circuhitin^  blood 
'l"h.'  usual  statement  is  that  the  amount  of  blood  corresponds  to  one- 
tliirt.ciith  of  the  body  w.-ight.  This  is  too  hi^h.  The  average  amount  is 
mthcr  under  one-twentieth,  but  while  this  is  so,  a  robust  voung  athlete 
in,i\  have  twice  as  much  l)l(.od  per  kilo  of  body  weight  as  has  his  wirv 
^mmlparent,  although  both  appear  to  be  in  perftct  health. 

'rhtsc  facts  put  us  on  our  guard  reg .rding  the  value  of  specific 
i;rii\  it\  determinations  and  red  corpuscle  ounts.  The  same  results 
iis  rcfiiirds  heightened  specific  gravity  or  increase  in  the  number  of 
(T.\thr.Kyt«>s  may  be  produced  equally  by  an  increased  pro<luction 
of  (•<.r|)iis(les.  and,  on  the  other  hand,  by  reduction  in  the  fluid  of  the 
lilood.  The  same  is  true,  mtifnth  mutandis,  with  regard  to  lowered 
s|)(rific  gra\  ity,  or  decrease  in  the  number  of  corpuscles.  Without  a 
.lit.rmiiiation  of  the  amount  of  circulating  blood,  enumeration  of  the 
(•(irimscles  gives  us  no  sure  information  regarding  variation  in  the 
prodiictioii  or  destruction  of  the  corpuscles.  Indeed,  with  this  fuller 
knowledge  we  are  beginning  to  find  out  that  conditions  which  hitherto 
liii\("  Iktu  classed  among  the  anemias,  or  states  of  insufficient  blood 
l.ro,hi,tioii,  are  truly  conditions  of  hydr-  r-ia,  or  dilution  of  the  blood 
aiwl  actual  increase  in  its  amount.  There  exist,  that  is,  states  of  true 
o k'.ima,  or  diminution  in  the  amount  of  circulating  blood,  and  of 
pictliorii  or  increase  in  the  blood  volume. 

OUgemia  (Ischemia).— This  dimiimtion  in  volume  mav  be  found  in 
some  secondary  anemias  and  in  pernicious  anemia.  In  these  condi- 
tions w(.  find  at  autopsy  not  only  that  the  blood  is  thin  and  of  a 
!>al<'  <  Hl<.r.  but  that  the  amount  of  the  blood  in  the  heart  and  vessels 
i>  iiotahly  small.  Like  reduction  in  quantity  may  follow  extreme  or 
ri|..  Mt.d  hemorrhages  or,  again,  great  loss  in  the  fluid  part  of  the  blood 
as  orjurs  111  cholera  and  pernicious  vomiting.  In  this  latter  ca,"  the 
tliinl  left  111  the  vessels  is  thick  and  tarry,  owing  to  concentration  of  the 
•  orpiiM  escmtrary  to  what  occurs  after  extensive  hemorrhage,  when 
"li^'t  Nond  there  is  is  singularly  pale  and  thin,  owing  to  the  passage 
into  ( |„  vessels  ot  tissue  fluids,  in  order  to  make  up  for  the  loss  of  blood 
pro]i(T. 

Plethora.    .Adequate  nutrition,  with  active  development  of  the  mus- 

«Mli'r  ^Nstcm.  ,s  f,„uid  to  be  ass.)ciated  with  increase  in  the  amount 

o   I.I00.I  above  the  normal.    There  is  thus,  contrary  to  the  teaching 

tnat  I,,,.  pn-vaile<l  for  some  years,  such  a  condition  as  simple  plethora. 

"itli  i.ii>  j.lso  exists  pathological  plethora,  as  seen  in  obstructive  heart 

;i'Mi<-  .  uhere  the  bhunl  is  apt  to  l)e  darker  than  normal,  owing  to 

■iP'T.   t  uxKlatioii,  although  estimati..n  of  its  specific  gravitv  shows 

.  t  It  !   more  dilute  than  normal  (hydremic  plethora).    We  do  not  wholly 

"  T-.:,.  ,1  what  are  the  conditions  that  lead  to  this  hv<lremic  state 

I"  iHiii    ,|isease.    A  similar  condition  has  also  lieen  noted  in  cases  of 

ti,;rr."'"'     ."*-'  l''.f"'''-    ^  «'""*'^hat  ditrerent  type  is  the  plethora 
''-'t  ""    A.  tlie  daily  consumption  of  many  liters  of  light  beer,  allied 


336 


THE  CARDIOVASCULAR  SYSTEM 


with  the  so-called  Muiiicli  heer  heart.  In  these  eases  the  heart  is  found 
much  hypertrophied  and  dihited,  clearly  in  response  to  the  larRer 
amount  of  fluid  which  is  al)sorl)e<l  from  the  alimentary  canal  in  succes- 
sive tides,  necessitating  inerease<l  work  to  pump  the  increased  volume. 
Yet  another  form  of  plethora  is  seen  in  chronic  Bright's  disease,  attrib- 
uted by  some  to  reduced  discharge  of  water  throuRh  the  damaged 
kidneys,  by  others  to  retention  of  chlorides  in  the  tissues  and  the  asso- 
ciated necessity  of  increased  fluid  for  their  due  solution.  Here,  also, 
there  is  a  heaping  up  of  lymph  and  fluid  in  the  tissue  spaces  (anasarca). 

Alteration  in  Distribution  Due  to  Cardiac  Disturbance.—It  is  obvious 
that,  the  blood  being  kept  in  motion  by  the  heart,  disturbances  of  that 
organ  materially  affect  the  quantity  of  blood  in  the  veins  and  arteries 
respectively.  These  disturbances  may  be  liroadly  divided  into  three 
orders:  (1)  those  involving  the  heart  muscle;  (2)  those  of  the  valvular 
apparatus;  and  (3)  those  of  the  nervous  mechanism  controlling  the 
heart  beat.  By  each  and  all  of  these  the  pumping  action  of  the  heart 
may  be  modified. 

Disease  of  the  heart  muscle  leads  to  weakening  of  the  same,  so  that 
the  organ  is  incapable  of  propelling  the  adetiuate  amount  of  blood 
either  from  the  right  ventricle  through  the  lungs  into  tli''  left  heart, 
or  from  the  left  ventricle  into  the  systemic  arteries.  Similarly,  imper- 
fect action  of  the  valves  results  either  in  direct  obstruction  to  the 
inflow  of  the  blood  through  the  narrowed  orifices,  or  to  indirect  obstruc- 
tion, from  regurgitation  of  blood  already  forced  forward,  through 
valves  that  arc  incompetent  and  patent  when  they  ought  to  be  closed. 
In  both  orders  the  result  is  an  arrest  of  the  inflow  .>f  the  blood  with, 
as  a  result,  a  {jru^ressive  accumulation  of  blood  -m  the  venous  side  of 
the  heart;  overfilling  of  the  veins,  whether  of  the  lungs  alone  or 
of  both  lungs  and  the  various  organs;  relative  deficiency  in  the  arte- 
rial blood  supplied  to  the  various  organs,  and  lowering  in  the  arterial 
blood  pressure.  The  effects  of  this  we  shall  discuss  under  the  heading 
of  Passive  Congestion  (.  33S).  Where  the  left  ventricle  v.t  vahes  of 
the  left  heart  are  involved,  the  pulmonary  veins  exhibit  distension  and 
increased  pressure  with  congestion  of  the  lungs  and  all  its  attendant 
disturbances  of  respiration.  This  throws  increased  work  upon  the  right 
ventricle,  which  undergoes  hypertrophy  and  dilatation,  and  eventually, 
the  right  heart  becoming  unable  to  overcome  the  obstruction,  there 
results  also  congestion  of  the  systemic  venous  system. 

Disturbance  of  the  cardiac  nervous  system,  whether  acting  more 
particularly  upon  the  vagus  paths,  the  accelerators,  or  the  intrinsic 
nervous  mechanism,  lea<ls  to  alterations  in  the  frequency  or  the  regu- 
larity of  the  heart  beat.  Tachycardia,  or  increased  rate  of  beat,  may 
eventually  lead  to  heaping  up  of  blood  in  the  systemic  veins  in  c.nse- 
<iuence  of  shortened  diastole  and  imperfect  filling  of  the  ventriilea. 
Bradycardia,  or  slowing  of  heart  beat,  may  lead  similarly  to  dct.  itive 
filling  of  the  arteries  with  resultant  accumulation  of  blood  on  ti.'  :ight 
side  of  the  heart. 


lU^ 


JtSTil 


THE  BLOOD 


337 


Alterations  in  the  Distribution  of  tlie  Blood  Due  to  Disturbances  Affecting 
the  Vessels. — The  vascular  tree  is  so  extensive  that  it  is  capable  of 
lidldiiiK  very  much  more  than  the  normal  amount  of  blood;  the  vessels 
(if  tlic  liver  alone  fully  distendecl  are  said  to  be  capable  of  holding 
the  whole  of  the  circulating  blood.  Thus,  for  the  circulation  to  con- 
tiiiiic,  it  is  essential  that  the  vascular  channels  be  reduced  down  to 
siicli  a  width  and  extent  that  the  normal  amount  of  blow!  fills  them. 
Tlii>  is  brought  about  by  two  main  agencies,  namely,  arterial  contrac- 
tion (tone),  and  muscular  tone,  the  compression  exerted  by  the  partial 
(diit ruction  of  the  muscles  in  general  and  notably  those  of  the  abdom- 
iiiiil  wall.  The  existence  of  muscle  in  the  walls  of  the  veins  shows  that 
tlicM-  also  are  capable  of  variation  in  caliber.  The  recent  researches  of 
Vaiiilcll  Henderson  demonstrate  clearly  the  existence  of  a  venopressor 
mcclianism.  It  follo'vs  that,  by  the  action  of  one  or  other  factor,  the 
lilood  may  find  itself  in  relative  abundance  on  the  arterial  side  of  the 
(inulation  or  on  the  venous,  although  the  close  interaction  between 
till'  licart  and  vessels  may  bring  it  about  that  opposed  states  of  the 
arteries  may  result  in  the  same  general  eH'ects  upon  the  distribution 
(if  tlie  i)lood.  Kxtreme  contraction  of  the  arteries  and  arterioles,  for 
(Nainple,  may  result  in  an  obstructive  heaping  up  of  blood  on  the  right 
-ide  of  the  iieart,  but  so  also  extreme  dilatation  of  the  arteries  and 
arteridles  may  be  followed  by  such  a  'owering  of  the  blood  pressure  that 
tli:  cireuiating  Huid  caimot  bt  forced  through  the  veins,  but,  stagnating 
tli(  r( ,  atlords  a  similar  picture  of  passive  congestion.  We  have  already 
(IIm  ii-sed  the  effects  of  vascular  relaxation,  when  treating  of  Shock  and 
<'olla|)se  Ip.  17S). 

Local  Alterations  in  Bloou  >dpply. — Increased  activity  of  an  organ  or 
liart  i^.  as  is  well  known,  accompanied  by  increased  passage  of  blood 
t(i  the  same.  .Such  increase  is  largely  determined  by  the  vasomotor 
a|)i)aratiis,  although  at  the  same  time  there  are  indications  that  the 
n  a(  tidii  of  tile  lymph  in  the  part  has  a  direct  influence  upon  the  muscu- 
lature of  the  vessels.  The  lymph  may  become  more  acid  with  activity 
of  the  tissues  and,  further,  may  come  to  contain  other  diffusible  cell 
Iinducts  (•ai)able  of  acting  on  the  vessel  wall.  Many  other  influences 
ill  '.irinine  the  arterifd  supply  of  a  part,  as  again  the  passage  of  blood 
o'lt  I  if  it  through  the  veins.    We  thus  recognize  the  following  states: 

.ocal)  active  hyperemia,  due  to  increased  determination  of  blood 

part  through  the  arte.  •  ^ 

Ileal)  passive  hyper. '<!.;;,    lue  to  obstruction  to  the  discharge 

il  tiirough  the  veins. 

.ocal)  capillary  hyperenaa,  in  which,  with  no  change  in  the 

of  the  artery  and  n«)  obstruction  to  the  outflow,  a  hyperemia  is 

!  i)>  widening  of  the  abundant  capillary  channels  of  an  organ. 
!     !  iii-alj  anemia. 
Ac- .ft  Hyperemia  of  a  part  may  be  direct,  due  to  dilatation  of  the 
art.  -     "iipl>l.^  hig  that  part,  or  collateral,  due  to  contraction  of  other 
an.;       v hereby  the  blood  pressure  is  raised,  and  as  a  result  more 


t.  tli( 


ol 


i!'i 


III 


338 


THE  CARDIOVASCULAR  SYSTEM 


'I 
t 


blood  is  poured  into  tlu.nf  arteries  which  are  not  actively  contracted. 
This  latter  we  see  in  the  Jevcloijment  of  a  collateral  circulation  in  a 
limb  or  other  region  after  obstruction  of  the  main  artery.  The  direct 
form  is  brought  about  <>ithtr  by  stimulation  of  the  vasodilators  (neuro- 
tonic hyperemia),  a  paralssis  of  the  vasocontractors  (neuroparalytic 
hyperemia),  or  direct  local  action  of  physical  or  chemical  agents  on  the 
part  (warmth,  diminution  of  external  pressure,  after-results  of  tempo- 
rary ligation,  atropin,  croton  oil,  etc.).  Such  arterial  hyperemia  is 
characterized  by  increase  in  size  of  the  affectefl  part,  bright  red  color, 
increased  warmth  with,  it  may  be,  throbbing  and  pulsation. 

Capillary  Hyperemia  is  usually  classed  as  arterial.  We  are,  however, 
inclined  to  hold  that  the  "  active"  hyperemia  of  inflammation  is  due  not 
so  much  to  dilatation  of  the  arteries  going  to  the  inflamed  part,  as  to 
physical  changes  occurring  in  the  capillary  area  whereby  the  onflow  of 
the  blood  is  hindered.  In  all  viscera  possessing  muscular  walls  or 
capsule,  expansion  of  that  muscle  and  lack  of  tone  of  the  same,  pas- 
sively permit  a  dilatation  and  hyperemia  oi  ihe  capillaries  within  the 
viscera. 

Venous  Hyperemia  or  Passive  Congestion. — Obstruction  to  the  onflow 
of  the  blood  or  closure  of  a  vein  necessitates  that  the  blood  propelled 
from  the  artery  accumulates  behind  the  point  of  arrest,  unless,  that  is, 
there  be  so  extensive  a  collateral  network  of  veins  that  the  blood  can 
escape  through  these.  If,  however,  the  obstruction  is  beyond  the  point 
where  the  veins  of  a  part  converge,  then  accumulation  must  occur.  If, 
for  example,  the  ()l)struction  oc.-urs  in  the  right  heart  the  whole  systemic 
venous  system  is  apt  to  show  the  comiition  of  passive  congestion.  If, 
again.  thV  obstruction  is  in  tiie  left  heart  the  whole  pulmonary  area 
becomes  intensely  congested.  Thus  (1)  cardiac  weakness,  (2)  hin- 
drances to  perfect  inspiration,  as  from  jjaralysis  of  the  diaphragm  or 
accumulation  of  fluid  in  the  i)leural  cavity,  and  (.3)  arterial  dilatation 
with  lowered  blood  i)ressure,  all  lessen  the  onflow  of  the  venous  bloixl, 
aiK  i ,  to  a  greater  or  less  degree,  favor  venous  congestion.  Such  overfilling 
of  the  veins  tends  to  show  itself,  more  particularly,  in  those  regions  in 
which  the  veins  receive  little  sui)port  from  their  surroundings.  It  also 
must  be  remembereii  that  a  forward  passage  of  blood  through  the  veins 
is  aided  by  muscular  contraction,  as  again  by  the  negative  pressure 
on  the  thorax  during  inspiration,  and  lack,  or  relative  lack,  of  these  is 
also  a  factor  favoring  local  or  general  congestion.  It  is,  however,  where 
there  i-'  obliteration  of  the  venous  channels  that  the  passive  hyperemia  is 
apt  to  be  most  marked. 

As  a  result  of  this  damming  of  venous  blood  in  a  part  (1)  it  becomes 
enlarged  in  consequence  of  the  increased  amount  of  contained  blo(^, 
and,  secondarily,  as  a  result  of  increased  transudation  from  the  distended 
capillaries;  (2)" it  becomes  of  a  dark  purplish  color,  owing  to  the  dis- 
tension of  those  vessels  whose  blomi,  by  long  continuance  in  thein,  has 
become  intensely  venous,  and  (3)  where  superficial,  the  part  is  coolw 
than  the  surrounding  parts,  owing  to  the  slowed  circulation  and  increased 


■■■ 


A  -.vfi'i  -i? 


UUM4    iJHi 


PASSIVE  COXGESTION— STASIS 


339 


cells  iilso, 
Stasis. 

oil  flow  is 
(if  --tii^is. 


niiliiition.  Tlu-  1)I<)()(1  may  bwome  intensely  venous,  and  this  explains 
till  cyanosis  of  suHerers  from  passive  congestion.  The  vessel  walls  are 
apt  to  show  evidences  of  malnutrition,  the  epithelium  becomes  abnor- 
niiilly  stretched,  and  may  exhibit  fatty  degeneration,  and,  as  a  result, 
there  is  increased  transudation  into  the  tissues,  resulting  in  oedema. 
Where  there  is  venous  congestion  of  large  areas,  as  in  heart  disease,  this 
(edema  is  one  of  the  most  striking  features.  There  may  be  accumulation 
of  fluid  in  the  body  cavities  (ascites,  hydrothorax),' and  in  the  sul)- 
(utaiieous  tissues  (anasarca).  Perhaps  the  most  rapid  accumulation 
of  fluid  takes  place  when  the  portal  vein  becomes  blocked  or  obliter- 
ated. This  leads  to  a  very  quickly  developing  ascites,  presumably 
heeause  the  portal  blood  coming  from  the  intestines  is  more  toxic  and 
hariufiil  to  the  lining  endothelium  of  the  vessels  than  is  the  systemic 
Mood  in  g»>neral.  With  extreme  congestion  there  may  be  multii)le 
cajiillary  hemorrhages.  Lastly,  malnutrition  is  apt  to  ati'ect  the  tissue 
and  these  may  show  evidence  of  degeneration. 
Slowing  of  the  blood  stream  may  become  so  extreme  that  its 
c<>rni)Ietely  arrested,  and  there  is  brought  about  a  condition 
Tile  capillaries  of  a  part  are  found  intensely  distended,  as 
al-o  the  veins  (if  this  condition  is  caused  by  venous  obstruction);  the 
arteries  also  are  distended,  as  n  result  of  the  obstruction  in  front.  As  a 
eoii-t  (|uence  of  the  malnutrition  and  dilatation  of  the  vascular  walls 
the  fluid  of  tiie  blood  tends  to  escape  into  the  surrounding  tissues,  and 
tlie  more  concentrated  corjjuscles  become  so  compressed  as  often  to 
ui)i)(ar  as  a  homogeneoi.-s  hyaline  mass.  This  conglutination  must  not 
he  iiii>taken  for  coagulation;  with  removal  of  the  obstruction  and 
re>uni|iii()n  of  circulation  the  individual  corpuscles  may  again  become 
loo-<  !i(  d  one  from  the  other.  Prior  to  this  stage  of  conglutination,  the 
we,ik(  iiing  of  the  distendcfl  capillary  walls  may  result  either  in  escape 
cf  -oiiie  of  the  erythrocytes  into  the  :uirroundiiig  tissue  .,  either  through 
-^I'ac  (-  ill  the  walls  (hemorrhage  per  diapedesin,  see  p.  304),  or  as  a  result 
of  nciiial  rupture  (perrhexin). 

1  ht  causes  of  such  stasis  may  be  either  (1)  obliteraticm  of  the  efTereiit 
\<in  ol  the  part;  (2)  obliteration  of  the  afferent  artery,  with  regurgi- 
taiii.ii  „f  l,l„o.|  from  surrounding  capillaries  into  an  area  which  now 
ha-  no  stream  through  it,  but  has  become  a  "backwater"  (see  red 
infarct,  p.  ;!}4);  (3)  chemical  and  physical  agencies  acting  directlv  upon 
th.  ..iiMllanes  of  a  part,  c.  g.,  heat,  caustic  agents,  toxins,  and  other 
l>'"li'  iiiducuig  acute  inflammation  (see  p.  122). 
Local  Anemia.  Local  anemia  may  (1)  be  part  of  a  general  bloodless- 
after  profound  hemorrhage,  or  may  be  (2)  coUateral  or  compen- 
;i>  wlurc  the  determination  of  blood  to  one  region  leads  to 
i  lie  blood  supply  to  others,  as  is  well  seen  in  the  cerebral  anemia 
pe  (!>•  17S),  or  may  be  (3)  due  to  local  di'^turbance,  as  in  the 
'  iitraetion  of  the  artery  or  arteries  of  supply  of  a  region  (neuro- 
'  mia)  seen  in  Raynaud's  disease  (symmetrical  gangrene),  and  in 
■  ;heial  tissues  under  the  action  of  cold,  or  again  through  the 


III'  - 

>at'  ' 
iiiii'!. 

of    ,; 

>p;i-! 
tonic 

thr   - 


i-w  --^TW^'-.-wsriMr-. 


340 


THE  CARDIOVASCULAR  SY<TK\f 


lI. 


K    i 


pi 


i 

\i  I 


direct  agency  of  adreiiin  ami  other  vusocoiistrictor  drugs;  may  be  caused 
(4)  by  obstruction  to  the  arterial  inflow  to  a  part,  as  {«)  by  pressure 
on  that  artery  from  without  by  new  growths,  Hgation,  etc.,  {b)  by 
disease  of  the  arterial  walls,  (r)  obstruction  to  its  lumen  either  by 
foreign  bodies,  as  in  embolism  (p.  'A'A),  or  by  intravital  coagulation  of 
the  contained  blood  (thrombosis,  p.  K»),  (H)  section  of  the  essel,  etc.; 
may  be  caused  ('■>)  by  direct  compression  exertc«!  •  pon  a  j)art  ( P'smarcli's 
bandages,  pressure  of  aneurysms,  and  other  tumors  upon  the  surroniid- 
ing  tissues).  Pressure  is,  however,  more  apt,  save  when  extreme,  to 
tell  first  upon  the  less  rigid  veins,  and  as  a  result,  passive  congestion 
rather  than  anemia  is  the  more  frequent.  It  will  be  recalled  that  if  a 
pressure  less  strong  than  that  required  to  arrest  the  i)ulse  below,  is 
applied  around  the  proximal  i)art  of  a  limb,  the  result  is  a  well-marked 
passive  congestion  ami  swelling  of  that  limb,  and  thus  an  incarcerated 
hernia  presents  a  similar  venous  hyperemia  and  not  anemia. 

Itr.iiiltn  of  Loral  .iHfwm.— These  are  primarily  (I)  pallor,  (2)  some 
reduction  in  size  due  to  lessened  filling  of  the  vessels,  (:i)  firmer  con- 
sistency, (4)  lowered  temperature,  (.'>)  arrested  fimction.  With  these 
there  may  be  subjective  symptcmis- numbness,  "pins  and  needles," 
agonizing  cramps,  and  sometimes  intense  pain.  The  after-cH'ccts  may 
be  very  serious  uidcss  conditions  favor  the  develojjment  of  a  collateral 
circulation.    These  results  we  will  consider  in  some  detail. 

Closure  of  Vessels  and  its  Effects.-  Arterial  Occlusion.  —The  results 
of  closure  of  an  artery  are  influenced  by  many  factors:  (1)  the  rateof 
closure,  whether  sudden  or  gradual;  (2)  the  existence  of  anastomosing 
arteries;  {'A)  the  relative  size  of  these  collateral  vessels;  (4)  the  extent  of 
the  area  supplied  by  the  closed  artery;  (5)  the  arterial  blcxnl  piessiire; 
(ti)  the  venous  bloo<l  i)ressurc;  and  (7)  the  difl'erence  between  the  two 
latter.  Slow  occlusion,  for  example,  extending  over  days  (as  in  the  case 
of  disease  of  the  arterial  wall)  afl'ords  time  for  the  development  of  an 
adequate  collateral  circulation.  Such  collateral  circulation  may  be 
present,  but  the  anastcmiosing  vessels  may  be  of  insignificant  siz-,  and 
sudden  occlusion  in  these  cases  may  lead  to  death  of  the  tissues  of  an 
area  before  the  collat'ral  \essels  undergo  sufficient  distension  to  carry 
the  blood  supply  needed  for  the  part.  A  good  example  of  this  is  seen  m 
connection  with  the  heart.  Anastomoses  exist  between  the  dillVrent 
branches  of  the  coronary  arterv  ;  but  these  are  small,  and  as  a  result  a 
sudden  blockage  of  one  "branch  is  followed  by  death  of  its  area  of  supply 
(infarct  formation).  •  •  i   • 

This  presence  or  absence  of  anastomosing  arteries  is  of  high  impor- 
tance. Cohnheim  divide.1  the  arteries  of  the  body  into  two  onlers,  the 
iinaniomoKiiKi  and  the  hrmiual  or  end-arteries.  The  accompiinying 
diagrams  indicate  the  nature  of  the  two.  Of  the  former  tin  most 
.striking  example  is  the  circle  of  Willis;  the  siimstomosing  arterie-^  there 
are  so  eonsi<lerable  that  obviously  if  one  be  blocked,  blood  can  tasily 
flow  into  its  branches  from  the  other  contributory  vessels.  In  the 
muscles  also  and  'he  skin  (save  the  very  smallest  superficial  Mssels) 


mm 


■am" 


INFARCTIOS 


341 


:iiiM-tii!ii«)Sfs  are  ahuiuiunt;  it  rwinires  the  sinuiltancous  hlockajif  of 

I  viral   arterit's  to  arrest   the  circiilatioii.     Of  ('((linheim's  terminal 

iirtirits  the  most  marked  instances  are  th«'  artrrla  mitral i.t  ntlnce,  the 

niNil  artery  and  its  branches,  the  splenic  artery  anil  its  branches,  the 

FiQ.   180 


-  I'M,;,  „f  an  aniiHtomosing  circulatii.n.  If  a  branch  be  littaturcd  or  block..!  a»  at  a,  the  reRJon 
-uppl,,,!  I,>  ||„>I  brunch  rccfivcs  abunihint  bloo.l  throuRh  the  anastomoses  between  it  and  other 
artiri.  -. '.  ;,ii.l  r.  At  most  there  in  an  arrested  eireulalion  in  the  artery  itwif  as  far  a»  the  nearest  jioinl* 
"f  I'r  tiu'limir  or  ■-in:t>lonio»is  abnvi'  and  below. 

Kia.   ISl 


rccmi, 
rn-nlii. 


"  riiiinal  ariirial  system  in  which  the  anastomoses  arc  only  between  the  <  apillary  l.xtpii. 
'luit  a  iicaiiire  or  obstruction  at  the  poii.t  a  may  cut  ofT  the  whole  blood  supply  of  tba 
!  *'y  the  obstructed  artery  and  its  brunches,  unless  the  eapilhiry  circulati<m  provided  by 
t.ri.s  be  s.,  abundant  as  to  afford  nourishment  to  the  blocked  ares. 


iTt'  I'.  V  itliin  the  l)raiii,  and  the  spermatic  artery.     These  are  held  to 

!>""•  ■  -  foinmuiiiciitioii  between  their  oapiiiain  ureas  and  branches 

:'•  "'I  '  arteries  of  like  or  different  origin.    We  are  of  opinion  that  this 

'^  I'll  I  matter  of  degree.    Careful  study  of  the  kidney,  for  example, 


■M2 


THE  CARDIOVASCULAR  SYSTEM 


reveals  Dceasiniial  anastomoses  lietweeii  branches  of  tlie  cortieal  arteries, 
and  e\|»eriin«Mitally  it  <an  he  shown  that  nnderiviiiK'  tlie  eapsnle  the 
capillary  area  is  common  t(»  the  capsvihir  ami  the  cortical  arteries. 
In  the  heart  nmscle  also,  as  already  noted,  clear  arterial  anastomoses 
exist,  hnt  despite  their  existence,  identical  infarct  i)riMluction  occurs 
when  a  coronary  nrtery  is  blocked,  or  one  of  its  main  branches,  as  when 
the  arteria  centralis  retinie  becomes  obliterated.  TIh"  same  considera- 
tions apply  to  the  intestinal  arteries;  anastomoses  o<our  between  the 
snpirior  mesenteric  and  the  many  rami  iliKulrunU'x  of  the  pancreatico- 
dnodcnal  artery  abovi  and  the  mud  collri  of  the  inferior  m«'senterie 
below,  as  a^ain  between  the  successive  l)ranches  of  the  superior  mesen- 


Fia.   1S2 


The  main  trunks  of  a  ri)llatiral  liroulation  oatablisheil  by  means  of  the  intercostals  iinil  neck  vcswis 
between  thi^  areli  iit  tliu  acrta  and  the  dorsal  aorta  in  a  case  of  loarct.'ttiun  or  cungriiilal  olistmrlinn 
of  the  aorta  in  the  riKiou  of  the  diirtiis  Hotalli.  1,  region  of  coaretalion;  2.  anastoniotii-  lir:inrhi'9 
between  the  intercostal  arteries;  3,  subclavian  arteries.  Froi:  umn,  agoU  thirty-five  yiMrs,  (Vfter 
J.   F.   .Meckel  and  Tlioina  ) 

teric.  If  a  small  branch  of  this  last  be  blocked  the  anastomoses  may  be 
adequate  to  prevent  any  arrest  t)f  the  circulation;  if  a  larger,  j;anf,'reiie 
of  the  intestines  inevitably  supervenes  because  these  anastomost  s  iire 
inadecpiate.  It  w  not  the  cxixlvure  <ir  non-existence  of  anastoinoKcx  thai 
should  tronhic  us,  hut  the  presence  or  absence  of  culequate  an(u<tomo'<(K;  n 
the  surrounding  arteries,  whether  directly  or  indirectly  through  their 
capillaries,  cannot  rapi<lly  ati'ord  adequate  blood  to  preserve  the  \  itnlity 
of  the  area  whose  direct  supply  has  been  arresteil,  then  death  ct  that 
area  must  follow,  resulting  in  a  focal  necrosis,  when  only  a  small  capillary 
area  is  involved,  in  an  infarct  where  the  area  of  distribution  ni  an 
arterial  branch  is  involved,  and  gangrene  or  mortification  where  ow  of 
the  larger  arteries  supplying  a  part  is,  with  its  branches,  cut  oil  Irom 


-4  .-  iJBfct^  __ 


mm 


mmr' 


wMmpewm 


wmm 


INFARCTION 


343 


tlif  (irc'ulutioii.    These  three;  terms  iiuiicute  grades  of  extent  of  dis- 
iiirltaiice  rather  than  distinct  processes. 

Development  of  ColUterkl  Clrculatkm. — Where  a  large  artery,  such  as 
till'  femoral  becomes  suddenly  obliterated,  the  liinb  iK-comes  luunb, 
( if|(|,  and  paretic.  Slowly  during  the  course  of  days  it  regains  its  tem- 
1>(  rjitiire  and  muscular  power.  We  know  from  dissection  that  anasto- 
iiiiiM  s  fxist  between  the  femoral  aixl  its  branches  and  the  other  arteries 
of  the  lower  limb,  i)ut  obviously  at  first  these  cannot  suj)ply  sufficient 
IiIihhI  to  the  part.  The  returning  warmth  shows  that  gradually  these 
riilnr;;t'  until  the  collateral  circulation  becomes  comi)letc.  The  accom- 
pMiiving  diagrams  show  how  abundant  and  large  these  collateral 
cliiiiiiicis  may  become.  It  has  l)een  <letermined  "xperimentally  that 
iM  II  (■ai)illary  chamiels  in  this  process  of  distension  may  become  arterial, 
;;:iiiiiiig  the  structure  of  arteries. 

\ (lions  anastomoses  are  freer  and  more  widespread  than  are  arterial; 
ii^  a  result  the  extent  of  the  collateral  circulation  set  up  is  at  times  very 
ixtraiirdiiiary.  When,  for  exai.iijle,  the  jwrtal  vein  becomes  obstruct«'d, 
the  blood  from  the  abdominal  area  may  find  its  way  to  the  heart  through 
the  ((ironary  veins  of  the  stomach,  and  so  to  the  oesophageal  veins; 
tlirnii^'h  those  of  the  gastro-epiploic  omentum  to  the  diaphragm  and 
>ii  to  the  vena  nzygos,  through  anastomoses  between  the  inferior  niescn- 
t(  ric  and  the  hemorrhoidal  veins;  through  the  veins  of  the  round  and 
Misptiisory  ligaments  of  the  liver  to  the  epigastric  and  mammary  veins 
him!  >o  on. 

Infarct  Formation  and  Mortification. — Where,  as  above  noted,  the  anas- 
loiiiDM's  arc  inadecpiate  to  restore  the  circulation  before  the  tissues  die 
.1111 1  Ihtc  it  must  be  noted  that  tissues  vary  in  their  vitality  so  that, 
tiT  (  \aini)lc,  glandular  organs  are  more  sensitive  to  nutritional  changes 
tlian  arc  nniscic  and  connective  tissues),  then  a  characteristic  series  of 
iliaii^'cs  manifests  itself.  Of  these,  paradoxically,  the  first  is  a  swelling 
"I  the  ail'cctetl  area  so  characteristic  as  to  afford  the  name  given  by 
\  irrliiiw,  of  infarction  or  "stuffing."  T'.iis  swelling  is  due  to  great  dis- 
tiii^ioii  of  the  capillaries  with  blood.  They  become  intensely  con- 
j,'<  -i<  il,  and  at  the  same  time  the  tissue  cells  of  the  part  show  a  series 
I'l  '  ii;,ni;cs  ending  in  co(a|)lcte  death  and  failure  of  their  nuclei  to  stain. 
Iliiw  docs  this  ougestioii  come  about?  Cohnheim  hehl  that  as  with 
kjiig  of  the  artery  of  supply,  the  blood  pressure  beyond  the  block 
■lii'cd  to  nil,  and  as  the  surrounding  veins  have  a  positive  pressure 
Muod  falls,  as  it  were,  from  them  into  the  area  until  the  pressure 
r  n  aches  that  in  the  surrounding  capillaries.  The  matter,  however, 
1  ((iiitc  so  simple.  It  has  been  shown  that  in  the  ki<lney,  for  example, 
"ii^'cstion  becomes  even  more  extreme  when  both  the  artery  and 
t  ill  are  ligatured,  also  that  after  the  artery  has  been  ligatured 
1  Kintinues  to  be  dischari;c(l  from  the  vein.  Evidently,  therefore, 
I'atiral  arterial  supply  of  this  organ  through  the  capsular  vessels, 
■  !i  rough  the  pelvis  from  the  ureteral,  is  more  extensive  than  we  are 
imagine.    Wherefore  it  would  appear  that  after  ligation  of  the 


1 1 


l!  .  i; 


ti 


ill 


344 


THE  CARDlOVASCVt.AR  SYSTEM 


arttTv  inmn  to  a  jmrt  tin'  pressurr  (■(inimiiiiicntt-il  to  tin-  capillHry  «ir- 
ciilatioii  tliroii>;li  tins*'  collateral  artcrifs  is  siitticicnt  to  tlistt'iiti  tin- 
<ai)illarits  of  tlu-  airf(t«"l  area,  altlioii^'li  iiisiiffieii'iit  to  drive  the  ea|)il- 
lary  lilooil  forward,  or  to  supply  adequate  nutrition.  Tliis  iiniH-rfect 
aeration  in  itself  is  a  factor  in  the  loss  of  tone  nnd  dilatation  of  tlic 
caj)illaries. 

Kxi>erinients  Ity  (ireenfield,  of  KdinhurKh,  nnd  his  pupils,  confirniiiiK 
earlier  studies  of  Vulpian  and  Hardy,  demonstrate  that  in  its  first  stage 
— within  five  hours  of  the  obstruction — an  infarct  is  always  intensely 
conj;»'i^ted,  rt'ddisli-jiurple,  and  raised.  Later,  if  not  too  large,  as  both  the 
<ells  of  the  part  and  the  I)Io(hI  corpuscles  under);o  necrotic  chnn>tes,  tlie 
henioj;lol)in  hecon-es  diffused  out,  and  the  part  becomes  paler  and  of  a 
more  pinkish  color.  It  is  in  the  early  part  of  this  second  fMriiMl  that  the 
infarct  shows  best  the  condition  ternuHl  coagulation-necrosis.  The  cells 
no  longer  stain;  they  bt'conie  hyaline  or  very  finely  granular  shadows 
of  themselves.  At  first  the  individual  cell  outlines  are  still  distinguish- 
able; soon  tissue  cells,  cajjillaries,  and  their  contents  become  fused  into 
a  firm  homogeneous  or  almost  homogeiu'ous  hyaline  mass. 

In  this  way  the  hemorrhagic  or  red  infarct  and  the  "anemic"  or 
"white"  infarct  may  be  regarded  as  two  stages  in  the  one  process.  Hut 
here  certain  comi)lications  enter:  (1)  the  hemoglobin  may  not  diffuse 
out  of  the  centre  of  a  large  infarctous  area  so  that  there  may  be  eom- 
j)lete  hemorrhagic  necrosis  without  pallor,  and  (2)  in  certain  ti-sui'-. 
(lung,  liver)  the  infarct  does  not  proceed  beyond  the  red  stage,  and 
that  because,  owing  to  the  existence  of  a  double  hUnnl  supply,  the  coag- 
ulation necrosis  stage  is  not  reacheil.  Thus,  if  a  branch  of  the  pul- 
monary artery  becomes  occluded,  the  residt  is  intense  congestion  of  the 
region  of  supply,  congestion  so  intense  that  the  corpuscles  escape  into 
and  fill  the  alveoli;  but  sufficient  blood  still  reaches  the  alveolar  walls 
through  branches  of  the  bronchial  arteries  to  nuiintain  their  vitality. 
.Similarly,  if  a  branch  of  the  portal  vein  be  occluded,  a  like  red  infarct 
is  profluced,  but  tlu>  liver  cells  do  not  undergo  necrosis,  gaining  sufficient 
nourishment  through  the  branches  of  the  hepatic  artery. 

It  follows  thus  that  the  red  or  hemorrhagic  infarct  is  of  at  least 
three  orders;  and  a  fourth  may  here  be  noted,  namely,  that  the  local 
death  of  tissue  accompanied  by  intense  congestion  and  all  the  features 
of  infarct  formation  may  wpially  be  brought  about  by  occliiitioii  af  the 
efferent  rein  of  the  ixiit,  provided  that  there  be  no  adequate  anastomoses. 
While,  for  example,  the  majority  of  red  infarcts  in  the  lung  appear  to 
be  due  to  blocking  of  a  branch  of  the  pulmonary  artery,  in  a  certiiin 
number  of  cases  a  like  condition  is  produced  by  intravital  coagulatinn  of 
the  blood  in  a  bram  'i  of  the  pulmonary  vein.  It  can  easily  be  imaginid 
how  in  these  cases,  o\\  ing  to  hi'k  of  exit,  there  is  most  intense  conge>ti()n 
of,  with  hemorrhag<  from,  the  capillaries  of  the  affected  part,  and  liow 
the  stif^i-  i-  liji'-ie  t<  'r  followed  by  tis.-i--  :!eath.  This  venous  f"r!M  is 
always  of  the  '  i  nionhagic  type.  .\u  organ  in  which  it  is  apt  to  occur 
is  the  adrenal,  .md  this  jjarticidarly  in  young  chihlren,  in  them  iKing 


lAM 


tSFANrTIO\' 


345 


;i  r.iiiM'  of  ri'intivfly  smldfii  <lratli.    Tlu-  \vli(»l«  oririm  is  t'ouiid  iiitciisi'Iy 
lit'iiiiirrliiiKic. 

It  ilfsrrvos  note  that  artcrirs  of  the  ttTiiiiiial  t\  pc  most  frf(|ii(iitly 
( \liiliit  a  tlichutoiiioiis  hranclnii^  and  sprt  ad  thus  from  tht*  hihis  of  an 
iiri:;iii  ill  a  fan-like  maiiiier  toward  the  periphery.  The  typical  infarct. 
iliiTtt'ore,  is  wedge-shaped ,  with  the  apex  directed  toward  the  hilus,  and 
till  Itase  heneath  the  surface  of  the  organ.  \Vl'  say  hvumfh.  because 
ii-iiiilly  the  infarct  does  not  come  absolutely  to  the  surfac*-.  In  general. 
;i  -iiperficial  layer  is  to  Ih"  nuule  out  of  tissue  that  is  congested  hut  not 
iircrKsed,  tissue  that  is  preventeil  from  necrosis  hy  the  collateral 
I  in  Illation  established  in  it,  throngli  the  capsular  vessels. 

//(.»////.»  oj  Infarction.  -1.  Complete  Besolution.-Coniplete  resolu- 
tion limy  occur  where  the  infarction  is  imjierfect  and,  as  in  the  lung. 
iliio  not  n-siilt  in  complete  necrosis.  Capillary  infarcts  and  focal 
iiicniso  may  also  lie  followed  hy  no  ol)\ioMs  riMilts,  the  destroyed 
ti-Mic  cells  heing  replaced  hy  regeneration  after  leukocNtes  have 
inii:riit(«l  into  the  part,  and  have  aided  in  the  digestion  and  removal 
111  I  he  necrosed  tissue  and  fibrin. 

:'  Organizatioii  and  Clcatriiation. — These  are  the  typical  events  in  the 
nnliiiiiry  infarct.  N'ery  rapidly  the  necrosed  wedge  of  tissue  is  fotind 
^iirmiiiided  by  a  zone  of  pronounced  congestion,  with  leukocytic  migra- 
tion into  the  n»'crosed  area,  and  at  the  {wriphery  there  may  be  a  certain 
iiiiionnt  of  regeneration  of  the  tissue  cells  i>roper.  In  the  more  central 
arc;!  the  dead  tissue  is  removed  by  the  agency  of  the  leukocytes  and 
ti"ii(  IVrineiits,  and  now  gradually  the  central  dea<l  area  becomes  the 
~i;ii  of;i  ])rogressivcformati(mof  granulation  tissue;  new  capillaries  pass 
ill  troni  the  surrounding  vessels  and  become  clothed  with  fibrofilasts 
iiiiiil  II  new  connective  tissue  eonii)letely  replaces  the  dead  tissue,  and 
till  II  .liter  the  nature  of  new  connective  tissue,  undergoes  pronounced 
loiitriiition,  so  that  the  end  result  is  the  ])roduction  of  a  dense,  di*- 
jin  (il  scar  of  firm  connective  tissue.  Not  infrequently  we  meet  with 
till  •  (1(  jircssed  i-icatrices  of  oh!  infarcts  in  the  kiilncv  and  the  s|)leen. 

'  Cyst  Formation.  Where  there  is  little  reaction  on  the  |>art  of  the 
-iirriiiiii.linjr  connective  tissue,  autolytic  changes  rest ;  -  in  the  necrotic 
ti~  111  iicconiiiig  eventimlly  replaced  by  a  .serous  fluid,  encapsulated 
\Miliiii  ;i  relatively  thin  layer  of  conntctive  tissue.  Such  cyst  forma- 
tion ii!ise(|iient  to  old  infarction  is  most  frequentlv  met  with  in  the 
-ec  p.  2!»4). 
Suppuration. — .Suppuration  may  occur  in  small  infarcts  where  the 
I  11-^  l>een  due  to  infected  material  in  the  blood  stream.  As  the 
'  r!;aiiisnis  multiply  and  toxins  dilftise,  leukocytes  may  be  attracted 
ircii  ill  such  abundance  that  a  true  abscess  replaces  the  infarct, 
trefaction. — Where  the  infarct  is  larger  and  becomes  infected, 
riiiiiiiition  of  leukocytes  to  the  i)art  may  be  inadequate,  and 
urnwth  of  the  bacteria  the  cells  arc  broken  down  and  liqutfif-d, 
'f  imtrefaction  rather  than  of  true  abscess  formation  being 


or;ii: 

1 
1,1,.' 

lllilT, 

tot'- 

till' 


J' 


ki'l 


'It. 


:vMi 


r///?  CMiDKiV  \S(  ILMi  SYSTK.M 


:  1 :  -f 


r».  Calcification.  ISanly  <al<annus  salts  ina  !.<•  dtnoMtnl  iii  tin- 
infarctftl  an-n. 

Mortiflcation  or  Oanfrene.  \\»-  iia\<'  alnaHy  noted  that  wlnri'  litnhs 
or  lar^i-  anas  an-  iiiv<tlve<l  in  this  pnifrs-  tli.ro  \\v  sj:-ii'-  of  niurtifi- 
(iitioii  rather  tluui  of  infarct  f-Tinatioii.  In  thesi'  ...  >  Mprophytic 
..ruanisiijs  from  thf  surfa<-«-  ar.  a|)t  to  ^row  into  and  in\ail«-  tin-  .Icmj 
tissiir,  loading  to  e>  iisive  i>ntrffaction.  \\>  havt-  already  des<rilM<i 
tli«'  stap  s  and  forms  of  thi-  mortifiiiition  or  ^r^Minrciu'  (see  p.  :VJS'. 

Thrombosis.  Tlu  main  cause  of  infarct  foiiiiation  and  local  arrest 
of  the  <irciilation  is  cmhfli.iiii.  Unt,  as  dislodged  iiartieles  of  tliroinlti 
are  tile  most  rre(|nent  causes  of  embolism,  it  will  he  U'tter  to  discuss 
first  the  -.nitject  of  thrombosis. 

Tiirondiosis  is  the  intravital  <le|)osit  of  constituents  «>f  the  Idood  in  a 
solid  form  within  the  vessels.  It  is  a  process  frequently  found  at  |)ost 
mortems.  Here  we  nmst  distinfrnish  between  post  mortem  clotting  and 
intravital,  and  at  times  this  is  difficult.  The  followinR  are  the  main 
features:  (I)  bliMnl  that  has  clitted  in  vessels  after  death  (cmor)  has 
done  so  by  a  prixrss  identical  with  that  which  occurs  in  blotnl  removed 
from  the  l)ody.  It  is  a  true  coagnKition.  with  fibrin  formation.  (2)  It 
shows  no  stratification;  the  blood  has  coagulated  - /(  iiia.y.ir,  save  that 
just  as  with  blood  <-oagulated  slowly  outside  the  b«Hi> .  the  lighter  hiiko- 
cytes  ma\  rise  to  the  top  and  form  a  "  bufly  coat,"  so  sometimes  we  find 
tiiis  post  mortem  clot  red  througlioui,  at  I'ther  times,  notably  in  the 
auricles  of  the  heart,  we  fin<l  a  sn|)erficial  an  '  upper  pale  layer  and  a 
lower  mass  of  red  clot.  Where  there  is  a  (ondition  of  marked  leuko- 
cytosis, this  jjale  layer  is  extensive,  with  a  yellowish  tint  and  trans- 
lucency,  earning  for  it  the  title  «»f  "chicken-fat"  clot.  (:})  I'nder  the 
mi(  roscope  this  pi.st  mortem  clot  presents  the  same  appearances  of  a 
network  of  fibrin,  enclosing  ctkrpusdes,  which  is  seen  in  extravascular 
bIcMMl  clot.  (4)  It  is  moister  and  less  friable  than  is  an  ante  mortem 
thrombus.  (."))  It  is  not  ailherent,  but,  on  the  contrary,  is  easily  removed 
from  the  cavity  in  which  it  lies. 

The  tlironduis.  on  the  contrar.\-.  is  firmly  adherent  at  some  pouit, 
or,  if  not  adherent,  search  will  show  a  dctaduwl  surface  and  a 
region  in  the  vessel  or  cavity  where  it  had  i)reviously  been  attached. 
It  is  dry  and  more  friable;  sci-n  under  the  microscope  the  ariaii):e- 
ment  of'  its  constituents  is  different  from  that  seen  iti  an  extravascular 
dot. 

The  conditions,  in  short,  leading  to  coagulation  and  throml>osi  ■  are 
•liflereiit.  According  to  moilern  teaching,  coagulation  is  essentially 
liroiight  about  bv  the  formation  of  fibrin  as  a  fine  network.  It  is  here 
necessary  only  to  recall  that  this  formation  is  due  to  the  action  of  tibnn 
ftTinent  »>r  thrombin  ui)(>ii  certain  of  the  proteins  present  in  tlu'  I)Iih)<i 
plasma.  This  ferment  is  imt  present  in  the  normal  drculating^l^KXHl. 
but  is  produced  after  liic  t.l'XMl  is  disdiargcd  from  the  xesrvh  'y  the 
action  of  a  thrombokinase  upon  the  thromboeen  of  the  plasma  ui  the 
presence  of  calcium  .salts.    The  thrombokinuse  in  its  turn  is  supposed 


mmrM 


f.,-  -■A'^VAjs^^-^i 


TIIROMHOSIS 


MI 


to  Im>  iilHTutcd  in  tin-  hrciikinK  <f<>wn  itf  IcukiM-yteis  and  IiIimmI  plntflctH, 
iiitlioiigli  tisMic  (flls  also  may  ;  IFonl  ti  coftfnline  which  activates  the 
tlironilM»j{cn.  ()|i|mis*'(I  to  this  tlirt>inl)iikiiiasc,  there  exist,  accordinR  to 
lliiickc,  substances  which  hin<ler  cna^nhition,  niven  off,  more  particu- 
l.irly,  hy  tlie  endothelial  cells  of  tiie  vascular  intiina. 

The  characteristic  of  the  thrombus  is  that  the  fine  network  of  fibrin 
i-  not  an  essential.  I'erhaps  the  best  idea  of  the  nanire  of  thrombosis 
i-  gained  from  a  study  of  the  successive  stages  of  its  experimental  pro- 
iliiction.  It  is  well  known  that  if  a  forein"  IwHly  be  intriNiuced  into  the 
IiIimmI  stream  a  ch)t  or  thrombus  tends  to  f(»rii.  "round  it.  We  owe  to 
r,l>(  rth  and  .'<<hii»melbusch  the  first  clear  stu(i..  ujMin  what  (K-cnrs  in 
thi>  pnx'ess.  Tliey  intHNluced  a  fine  needle  point  through  the  vessel 
u;ill,  and  observed  u  very  striking  process;  namely,  they  fouiid  that  the 
tir-^t  step  is  the  accumulatioi.  upon  the  foreign  IxMly  of  UIihhI  jtlntelrUt. 
Whiit  these  blo(Ml  platelets  are  has  been  subject  of  debate,  but  this  is 
<iTtain  that  they  are  present  in  varying  munbers  in  normal  blood,  and 
that  a  reduction  in  their  number  characterizes  conditions  in  which 
there  is  delayed  or  imperfect  -  agulation  of  the  bliMwl  (hypinosis). 
Thi'  -fiidies  of  J.  II.  Wright  have  <lemonstrated  positively  that  sonic,  at 
Iciist,  of  them  originate  in  the  bone  marrow  by  the  breaking  off  of 
jiroccNses  from  the  megacaryoeytes  of  that  tissue.  .Vriiold  and  others 
li'ilil  that  some,  at  least,  originate  from  red  corpuscles,  .\ccumu- 
iiitiil  tluis  the  blood  platelets  run  together  or  \  .'ilergo  conglutination 
int. I  :i  Immogeneous  or  fitoly  granular  mass,  and  not  it  to  fibrils,  and 
"ith  siicctssive  deposit  ot  lore  bloo<l  platelets  the  v>  -.  ''.men  may 
iixcptiic  filled  with  (1)  a  pnr.  hyaline  blocKl  platelet  thr.  :,:  i-  Often, 
linwever,  tiu'  leuk(K-ytes  of  the  circulating  blocxl  also  b.  \"  '••■  :,  ri.  ent 
to  thr  nias-  when  we  s|,.ak  of  (2)  a  mixed  blood  platelet  •!  i.  .livj  -yte 
thr.iiibiis.  Or,  under  ct  rtain  conditions,  more  particulflT  ■'.  •  there 
i-  irtiiiouriced  st:i-is  of  the  blood,  a  thrombus  beginning  'hus  passes  on 
til  the  (nnditioii  ukiu  to  eoagulaticm  propt>r,  and  coarse  hyaline  bands 
!iii<!  processes  of  coiigIutinate<i  material  enclose  in  their  meshes  the  red 
"TiniMlts,  so  that  (;{)  a  mixe<l  red  thrombus  is  produced. 

Tht  M'  are  tlie  main  types,  but  also  in  the  smaller  vessels  we  <.rca- 
Mnn.illy  encounter  (4)  hyaline  thrombi,  which  it  is  difficult  to  ,  -.pJain 
"iIhi  than  as  dtie  to  a  conglutination  or  agglutination,  not  ot  blood 
I'l  iti  h  ts,  but  of  red  corpuscles,  jis  may  be  seen  in  inflammatory  stasis 
!-■'   I'll:.  KiO). 

/  •'  'oM  F'trorlng  Thromhoaui.  -1.  Loss  of  the  Integrity  of  the  Vascular 
EnrtotheUum.  This  is  a  factor  of  the  first  order.  Haumgarten  and 
liiiye  slunyn  that  the  blood  may  be  kept  ffuid  for  ilays  when 
I  ill  a  vein  between  two  ligature  .  or  in  a  "living  test-tube," 
ed  of  a  vein,  ligatured  before  removal  from  the  body,  and  then 
:it  on»-  end,  provided  that  in  ligation  the  endothelium  has  not 
'li'ueti.  On  the  other  hand,  the  .iestruction  of  the  endothelium, 
I  evpirimentally  or  by  disease,  is  foiiov,  .1  by  ihrombosis. 


cm 

cnli 


Wllr 


^ 


348 


THE  CARDIOVAfin'LAR  SYSTEM 


t- 


t:U 


I-'' 


2.  Slowing  of  the  Blood  Current  and  Stagnation.  Lar^o  tliroiuM  occur 
in  areas  like  aneurysms,  wIutc  tlic  l)lo«)(l  stream  is  slowed;  where,  as  in 
arteries,  tiie  stream  is  rapid,  tiiere  may  l)e  little  or  no  tlir<unl)osi;  Thus 
thrombosis  is  much  more  common  in  the  venous  than  in  the  arterial 
system. 

'A.  Eddying  of  the  Blood. — \'on  IlecklinKnausen  held  that  this  rather 
than  simph-  stagnation  explains  the  fre<iuent  origin  of  thrombi  in  the 
jjockets  of  tht.  valves  of  the  veins.  The  centre  of  an  eddy  may  be 
recalled  as  relatively  stagiuint,  aiid  the  more  ])eripheral  whirl  brings 
successive  cells  or  blooil  platelet  into  approximation  with  the  surface 
of  the  developing  thrombus. 

4.  Hemolysis. — Agents  leading  to  cor[)Uscular  disintegration  favor 
extensive  thrombosis.  Such  agents  favor  more  rajud  coagulation  (or 
hyperinosis) .  Among  them  we  may  mention  burns  and  freezing  of 
parts,  transfusion  of  blood  from  another  individual  or  species,  and 
various  jjoisons,  snake  venom,  foreign  enzymes,  ricin,  toluylene-diamin, 
extracts  of  amanita  and  other  poisonons  mnshrooms,  and  the  products 
of  cell  degenerntion.  Of  the  same  order  may  be  cited  the  toxins  of 
infections.  Thrombosis,  ft>r  example,  is  not  uncommon  as  a  compli- 
cation of  tyjjhoid  and  other  infectious  conditions.  In  s(mie  of  these 
cases  we  deal  with  a  bacteriemia  and  find  (as  in  acute  endocarditis)  that 
there  has  been  a  primary  injury  to  the  vascular  endothelium.  Such 
thrond)i  in  themselves  contain  abundant  bacteria.  In  other  cases, 
however,  the  thrombi  are  sterile,  and  in  these  we  must  suppose  that 
the  circulating  toxins  are  the  imjjortant  factor  both  in  injuring  the 
vascular  endothelium  and  in  bringing  about  an  increased  (oagulatior. 
power  of  the  blood,  this  hyperinosis  and  the  liability  to  throniltus 
formation  appearing  to  proceed  hand  in  hand. 

Forms.— Thrombosis  may  occur  in  all  parts  of  the  circulation  proper. 
(a)  Cardiac  thrombi  are  frefjuent;  the  sites  of  election  here  are  in  the 
auricular  appendices,  and  in  the  ventricles,  originating  either  at  the 
apices  or  in  the  pouches  between  the  nniscle  bunilles.  All  these  are 
areas  of  relative  stagnation  of  the  blood,  and,  it  may  be  aihled, 
of  poor  nutrition  of  the  cardiac  endothelium.  Originating  thus  tluy 
tend  to  form  sessile,  more  or  less  globular  nuisses,  and,  under  the  action 
of  the  blood  current,  often  i)resent  a  ribbed  or  coarsely  netted  surtiiir. 
They  are  of  some  little  duration.  .After  a  time  these  thrombi  proiiit 
a  comparatively  thin  surface  layer,  enclosing  a  turbid  fluid,  the  cciitre 
of  the  mass  having  undergone  li([uefaction  through  autolysis  or  ieiiki)- 
cytic  heterolysis.  More  rarely  such  a  globular  thrombus,  originiiting 
in  one  of  the  auricular  appendices,  be<()ines  i)edunc\date  with  pro- 
gressive growth,  and,  being  broken  off,  forms  a  ball  thrombus.  Irce 
in  the  auricular  cavity,  such  ball  thrombi  iiave  been  found  to  hv  ii 
cause  of  sudden  death,  acting  like  a  ball  valve  and  occluding  a  narmwcd 
mitral  orifice. 

Yet  another  form  of  cardiac  thrombosis  is  of  first  importance.  '1  hose 
above  mentioned  are  encoiuitered  in  cases  of  obstructed  circulation  iina 


THROMBOSIS 


349 


slowfd  1»1(mmI  flow,  whether  through  weakening  of  the  eardiae  miisele  or 
tlinniK'li  valvuhir  disease.  They  are  generally  rejjarded  as  hhiiid  and 
iioii-iiifective.  The  other  form  is  that  found  in  aeute  (l)aeterial)  endo- 
ciinlitis,  in  tlie  form  of  vefetations,  most  often  developing  upon  the  cusps 
of  one  or  other  heart  valve,  but  occasionally  also  growing  as  parietal 
tliriiMihi  upon  the  walls  of  ventricle  or  auricle.  Such  vegetations  may 
111'  ill  the  form  of  individual  i)rocesses  or  outgrowths,  or,  at  times, 
iimv  develop  into  large  cauliflt  wer-likc  masses,  adherent  to  the  valves. 

Fiu.  :»« 


(;i  .iHilar  thnimliua  of  uuriraliir  iipix'ndix:     ii,  (clobulur  thrrjinl)u»  filliiiK  mid  protruding  from 
the  auricilar  upiM-ndix. 


mm    / 


Fia.   1S4 


I'n:: 

ill-n    : 

leu'. 
Imt,. 

A 

VCIln 

aiiil 
^'nl^^ 


(llobiiliir  throinhus  of  apex  of  left  vi'Htricli'. 

'Iicir  <(>nsist»-ncy,  and  from  the  motion  of  the  blond  current,  as 
111  the  softening  they  may  undergo  through  the  actiot)  of  the 
'I  t'lrnicnts,  vegetations  of  this  nature  are  jMculiarly  liable  to 
l>rnktMi  olf  and  be  (arried  forward  in  the  blood  stream. 
n;idy  noted  (h)  arterial  thrombi  are  not  so  fn-fiuent  as  ar»- 
Nevertheless,  they  may  develop  both  in  the  pulmonary  artery 
•lie  iiurtii  or  its  branches.  More  fnHiuently  they  are  parietai, 
Ironi  some  diseased  area  of  the  arterial  wall,  and  at  times  thev 


3r)0 


THE  CARDIOVASCULAR  SYSTEM 


rm 


Kiu.   185 


niay  conipli-tc'ly  fill  the  vessfl,  forming  an  occluding  thrombus.  It  !> 
interesting  to  note  that  it  is  excejitional  for  such  arterial  thrombi 
growing  downward  to  extend  into  the  cai)illaries.  Wiien  (c)  capillary 
thrombosis  occurs  it  is  due  to  direct  local  irritation  or  disease. 

id)  Venous  thrombi  are  relatively  common,  occurring  in  the  pul- 
monary, the  systemic,  and  the  portal  circulation.    The  slower  flow  of  the 

blood,  its  poorer  quality,  the  presence  of  the 
valves,  the  low  blood  pressure,  and  easy  com- 
pressibility all  favor  thrombosis,  and  once  the 
process  has  begun  in  a  vein,  it  is  apt  to  ex- 
tend in  both  directions,  so  that,  for  example, 
a  thrombus  originating  in  the  femoral  vein, 
may  exten«l  up  int  i  the  iliac  veins  and  involve 
nil  the  brandies  of  the  femoral  below,  while  a 
thrombus  forming  in  the  eins  of  the  uterus 
may  progress  until  it  fills  the  internal  iliaes 
of  either  side. 

The  Rcsulin  of  Thrumhosis.—Xn  obliterating 
thrombus  of  a  vessel  produces  those  c(>ii(li- 
♦^ions  t)f  arrested  circulation,  in  the  area  of 
supply  or  origin,  that  have  already  been  dis- 
cussed. If  the  thrombus,  or  part  of  it,  be- 
'•onies  loosened  am!  carrie<l  along  the  blood 
stream,  its  efi'ects  are  tho;<e  which  we  shall 
discuss  in  our  next  section  when  treating 
of  embolism. 

.\s  to  the  changes  that  may  occur  in  the 
thrombus  itself,  the  following  may  be  said: 

Once  laid  down,  the  fibrinoid  framework 
of  the  thrombus  tends  to  contract  and  drive 
nut  the  cNcc^s  of  plasma,  hence  the  throiiiiiiis 
becomes  relatively  dry.  If  the  thronilms  is 
small,  the  iiulieations  are  that,  through  the 
agency  cf  leukocytes,  it  may  (1)  undergo 
complete  absorption  and  removal,  witli  rt- 
stonitinii  of  the  circulation  to  the  jxirt,  i.r 
(2j  it  in;iy  undergo  organization.  We  Imve 
already  i)oiiitt(l  out  that  :'t  the  regidn  of 
iittachnuiit  of  the  thrombus  the  lining 
endotiu  limn  of  a  vessel  is  destroyed.  It  is 
at  this  point  that  the  thrombus  actinir  l»oth 
as  a  fireign  body  and  irritant,  leuk<(>tes 
make  tiieir  way  into  it  from  the  vasa  vasorum,  and  foUowing  ii|Hin 
these  there  is  a  passage  in  of  <!t[)illary  loops  and  processes.  In  this 
v  ty,  just  as  in  ordinary  granulation  tissue,  fir.-^t  there  is  a  solution 
and  progrtssivc  removal  of  the  thrombotic  material,  and  th'-i  i-  fol- 
lowed by  th,    laying  down  of  fii)roblasts  and  new  connective  ti-sue. 


\ri;tf  rf»i  thruininiK  i>f  iJi  i.   vein. 
'■  WcC.iW  M-'(h<-.iI  Mu!<.nirii  ) 


THROMBOSIS— EMBOLISM 


351 


The  thrombus  thus  eventually  becomes  ropreseiiteil  bv  a  shrunken 
ina.^  oi  dense  connective  tissue.  The  networic  of  new  capillaries,  in 
this  newly  formuig  tissue,  may  open  above  and  below  into  the  lumen 
i.t  the  vessel,  and  so  not  infrequently  we  find  the  development  of 
canalization,  one  or  several  channels  of  fair  size  restoring  the  contin- 
iiit)  ..t  the  vessel.  At  times  indeed  the  only  indication  of  an  old 
thn.!iil...sis  IS  the  presence  of  fibrous  bridges  stretching  across  a  vessel 
(li  Autolysis,  as  we  have  already  noted,  is  liable  to  occur  in  old 
ciirdiac  thrombi. 

(1)  Putrefactive  Softening.- Tl  is  rlso  has  alreadv  been  referred  to 
Imt  two  processes  must  be  distinguished.     There  mav  Im-  a  simple 
iMintorni,  but  not  truly  purulent,  softening  of  a  thrombus.    This   for 
(XiiiiipIjMs  not  infrequentlv  sjen  in  thrombosis  of  the  lateral  sinus'and 
iiitcni.-il  jugular  vem  foil:  wi.ig  upon  infective  middle-ear  disease     The 
thro.nl.ns  is  liquefied  tl.rough  bacterial  agency,  without  anv  marked 
iin  MH.m  by  pus  cell..    Or,  on  the  other  hand,  as  we  at  times  note  after 
app.  M.heitis,  progressive  thrombosis  of  an  infective  nature,  involving 
the  interior  mesenteric  vein,  may  either  be  the  result  of  an  ascending 
iNlertini,  of  the  Wall  of  the  vein,  or  may  itself  set  up  inflammation  of 
t  le  wall  (thrombophlebitis).     Where  this  is  the  case  there  mav  be  an 
iil'iiii.hdit  migration  of  leukocytes  into  the  thrombus,  and  silftening 
;i-<.ei;,te.l  with  true  suppuration.    (.-))  In  certain  regic.ns  of  the  bo.lv' 
^^li(re  there  are  abundant  venous  anastomoses,  as  in  the  uterine  -ind' 
prn.tatie  pl,-xuses,  we  encounter  phleboUths,  somewhat  elongated,  oval 
l""li;-.  lying  hu.se  in  the  lumen  of  a  vein,  which  have  undergone  calei- 
■M  atioM.    1  hese  are  old  bland  thrombi,  i.re  characteristicallv  unattached 
aii'l  ui.t.a.l  of  being  absorbe<l  they  beccmie  infiltrated  with  calcareous 
^ait--. 

Embolism.-.\ny  body  which,  carried  along  by  the  blood  stream 

iMitil  «ith  the  narrowing  of  the  lumen  it  \ ..mes  arrested  ami  blocks 

tlir  v.,mI,  is  known  as  an  embolus,  literally,  something  thrown  in 

/;  '"^;  (./    l:v,hohsm.~lt  is  interesting  to  note  how  maiiv  diverse 
i"'lM-,  It.ni-ii  to  the  normal  blood,  may  thus  cmstitute  emln^li 

Liberated  Thrombus  or  Vegetation.-  ( 1 )  Quite  the  .•ommonest  is  a  liber- 
""■  '^  '"'it.ns  „r  a  cardiac  vegetation.  The  for  .er,  liberated  in  the 
r^^tn, .  M.,iis,  nijty  either  become  arrested  in  the  right  heart,  c  >/  the 
'"N'i-  :.^t.  riusns.  „r,  passing  through  the  heart,  in  some  branch  of  the 
{"'"""I"-:  artery,  „r  originating  in  the  pulnionarv  vein-  or  left  heart 
"■""H.   ;irr,.st,.,l  „,  s<mie  <Mie  <.f  the  arteries,  or.  lastlv,  originating  in 

,;  '. ''  '•^^♦'•"'-  '^  arrestcl  in  the  liver.    .\  .h-tached  venous  throm- 

'- 1-  M"  ti'  l»e  somewhat  elongated,  is  apt  further  to  be  arrested  at  the 
I'lircatioii  of  a  branch  of  the  pu!inoiiar\  arterv.  .So,  often  it 
t  IS  known  as  -'riding"  emlM>lus,  riding  over  the  angle  of  the 

V ■^tending  d„\v„  the  two  branches.     It  is  apt  to  be 

'I""  11  the  two  branches  by  a  pr<Kvs.  of  secondarv  thrombosis 
''■■in  the  tree  ends. 


|"'iiit  , 
I'uriii- 
hii'uri  , 


3i52 


THE  CARDinVASn-LAR  SYSTEM 


'2.  Calcareous  and  Atheromatous  Emboli.-  ('alciircous  and  atliernni- 
atous  matter  from  atln'mmatous  ukvrs  may  also  potentially  form 
emboli,  hut  these  are  not  often  encountered. 

•\.  Cell  Emboli.  Tinnor  masses  and  cells,  orijjinatinj;  from  new  growths 
which  ha\c  penetrated  the  msscIs,  forming;  eml)oli,  may  continue  to 
grow,  and  thus  give  origin  to  metastases.  Tissue  cell  emboli  also  occur. 
Of  these  the  more  frcf|uent  are  placenta  cell  emboli,  derived  from  the 
fa'tal  villi,  which  have  penetrated  into  tiie  uterine  sinuses,  and  liver 
cell  emboli,  the  cells  being  liberated  into  the  hepatic  viin  after  some 
sharp  and  long  ci  m|)r<'ssion  \ipon  the  organ.  These  would  seem  to  he 
more  of  tlu'  nature  of  pathological  curiosities  than  causes  of  serious  dis- 
turbance. .\nother  cell  which  may  also  btconu'  liberated  into  the  cir- 
culation is  the  giant  cell  or  megacaryocyte  of  the  bone  marrow,  which  is 
apt  to  1h'  liberated  in  the  delicate  ca])illaries  in  cases  of  pronounced 
leukocytosis.  \'er\  rarel\'  osteoclasts  and  fat  cells  from  the  marrow 
have  been  detected  in  capillaries. 

Of  cells  that  luiturally  are  present  in  the  blocul,  the  leukocytes,  in 
cases  of  myeloid  leukemia,  may  be  so  densely  |)acked  into  the  caj)illaries 
of  \  arions  organs  as  to  constitute  emlM>li. 

4.  Fat   Embolism   follows   upon   extensive   concussictn   of   the  iioiiy 
skeleton,  sncli  as  may  be  caused  by  a  fall  from  a  height.    So,  also,  after 
fracture  of  the  long  boiu-s,  with  rupture  of  the  fat  cells  of  the  marrow, 
after  forcible  breaking  down  of  stiff  joints,  operative  handling  of  fatty 
tissiu's.    such    as    the   onu'ntmn  and  pamiicidus  adij)osus,    iiiiinenms 
ca|)illarics  of  the  lung  tnay  be  blockt'd  by  fat.    Where  only  a  few  cap- 
illaries  are  involved,  at  most  minute  infarcts  may  be  produced,  witli  no 
serictus  results.    There  may  be  a  small  surroimiling  congestion  aii<l  some 
migration  (»f  leukocytes;  gradually  the  fat  seems  to   become  siporii- 
ficd  and  so  remoxtd.     Its  presence  in  great  abundance  may  seriously 
obstruct   the  circulation   through   the    lung,  and    may   even  pnidiict' 
a   fatal  dyspncea.    The  emboli  may  become  loosened  from  the  liinj; 
capillaries,  and  passing  through  the  left  heart,  lia\c  been  encouiiiiTcd 
in  the  cai)illaries  of  the  heart,  kidney,  and  brain.     .\  sonu-what  -iiiilar 
condition  is  at  times  uu't  with  in  the  lipemia  of  diabetes,  but  lure  no 
reaction  is  seen;  apparently  the  tine  fatty  globules  present  in  the  hliiod 
have  run  together  and  creamed  as  a  post  mortem  phenonunon. 
Of  emboli  due  to  extraneous  matter  the  following  nuiy  be  noted, 
."i.  Air  Embolism.     The  negative  pressure  most  uuirked  in  the  -    iib 
lU'arest  to  the  heart  during  inspiration,  sonu'times  leads  to  air  I"  ini; 
sucked  into  one  of  thesi-  veins  during  the  course  of  an  operatiiiii.  or 
after  trauma.     If  the  (piantity  so  inspired  be  snudl,  no  result-  may 
ensue:  if  larger,  death  at  times  occurs  with  absolute  suddennc-:  at 
tinu's  after  a  |)eriod  of  extreme  dys|)nu'a,  with  cyanosis  and  con\nl  ions. 
("ases  are  on  record  wlicre  sudflcn  death,  apparently  due  to  this  ( aiise, 
has  tolhtwed  operation  upon  the  head  and  upper  extremities,  ami  troin 
entrance  at  the  placental  site  during  or  after  labor.    There  is  still   i>nw 
debatcas  to  the  exact  causeof  death.    Some  cases  arc  evidentl>  i.ir.iiac, 


-    PfL 


EMBOLISM 


353 


(liM  ti.  tlH>  expansion  of  tho  wanned  air  and  its  heeoming  churned  into  a 
In.i  li  in  the  heart,  the  froth  impeding  the  action  of  the  anrieuloventricular 
viihcs.  In  other  eases  the  formation  of  abumiant  eapiilarv  emboli  in 
III.'  hiiigs  or  brain  would  seem  to  be  the  lethal  agent.  Tlius  in  these 
(iiscs  the  lungs  have  shown  multiple  hemorrhages,  indicating  obstruction 
(if  a  hirge  num;,  r  of  capillaries,  with  congestion  and  rupture. 

(1.  Gas  EmboU.-  Rapid  death  may  follow  if  proper  precautions  be 
not  tiiki-n,  when  those  who  have  been  working  under  compressed  air 
rttiirn  to  the  ordinary  pressure.  There  may  be  either  pronounced 
ilyspiKca  and  asphyxia,  rapidly  fatal,  or  a  succession  of  nervous  dis- 
tiirhiiiKes,  which  may  be  recovercfl  from,  or  prove  fatal  after  a  few  days. 
Tlii^  caisson  disease  has  been  experimentally  proved  to  be  due  to  the 
iiK r.ased  solution  of  air  in  the  blood  under  pressure.  The  oxygen  of 
that  air  is  utilizwl  by  the  tissues,  but  the  dissolved  nitrogen  is  apt  to 
1m  IiIh  rated  from  the  blood  in  the  form  of  gaseous  bubbles,  as  gas  bubbles 
torin  III  a  soda-water  l)ottle  just  opened,  an<l  in  the  capillaries,  notablv 
tiioM'  (.t  the  brain  and  spinal  cord,  these  form  emboli.  The  injection  of 
iM  n.M.lc  of  hydrogen  into  the  cavities  of  the  body  has  been  followed  by 
'iTuw  <.rebral  symptoms,  apparently  dne  to  air  embolism,  and  in  a 
vii  nn  proportion  of  cases  of  infection  by  the  Bacillus  Welchii  the 
|iro.iurti.)ii  of  gas  in  the  vessels  o^-curs  ante  mortem,  so  that  gaseous 
iiii^iinli.iii  may  be  one  of  the  causes  leading  to  a  fatal  event. 

7.  Bacterial  Emboli.  Bacteria  may,  although  we  think  iiidirectlv, 
t'Tiii  cipillary  emboli,  whereby  we  mean  that  bacteria  carried  in  the 
i'i'  ■!  -tnam  may  be  arrested  by  the  capillary  emlothelium,  and  so  do 
'"  1  iimiir.liately  block  the  vessel,  but  multiplying  locallv  mav  eventuallv 
<iiiiip|.!(|v  occJiKJe  it.  V        .  . 

^  Pigment  Emboli.- These  occur  in  the  smaller  eapillarjes  of  the 
'"■'II.  I  In.  y,  and  other  organs  in  malaria.  These  emboli  are  composed 
"I  ilu  .l.l.ns,  pigmented,  of  the  hemamceba  of  malaria  left  after  the 
i"'n-  liiivc  l„.(.i,  discharged. 

''  Parasitic  EmboU.  (  losely  allied  is  the  accumulation  of  trypano- 
;"inr.  Ill  the  .■irebral  capillaries,  which,  according  to  some  observers, 
1-  I  in  Miaiii  ciiiis,.  „f  the  somnolence  characteristic  of  sleeping  sickness. 

■  iM  imnisiles.  iich  as  the  abundant  larvie  of  various  strongyles, 
il;.  iii.ln. r  embolism.  After  the  rupture  of  an  eehinococcus  cvst. 
'  I  tlie  .laughter  cysts  may  find  entrance  into  a  vein  and  so  lead 

'i-iu  of  a  iJiiJmonary  ves.sel. 
Foreign  Bodies.     Lastly,  some  three  eases  are  on  record  in  which 
•  '"Ting  (he  heart  or  larger  vessels  have  been  carried  along  in 

'  stream  until  they  have  become  fixed  in  some  smaller  artery. 

"■ir^-cives  seen  a  bullet  lo<lged  in  the  femoral  arterv  after 
Ml.  anterior  wall  of  the  dorsal  aorta. 
'     ;'/^  of  i:mfmlLwi.     These  have  already  been  discussed  when 
I  -     t  the  ( losiire  of  arteries  an<l  infarct  formation.    To  repeat, 

■  ';  mtar.t  be  formed  or  not  depends  upon  tlie  extent  of  the 
ir(  Illation.    As  to  tlie  result  iijxm  the  vessel  itself,  there  may 


M 

Ilia, 

-oliir 
to  .  : 

lull!,' 

Il,r|,i 

liiiT.; 
/■//, 

trciitii 
"lull, 

Inlhil. 


354 


TIIK  CARDIOVASCULAR  SYSTEM 


be  either  ..rRanization  and  t)hliteratioii  of  the  vessel;  abscess  formation 
where  the  emliolus  is  itifcctivr  aneurysm  formation  tliroiigh  weakening 
of  the  arterial  wall;  formation  of  metastatic  growths,  etc. 

Hemorrhage.— Ilemorrhapc.  the  act  of  escape  of  hlcnn]  out  of  the 
ve:.  'cls,  and  the  results,  lociil  and  general,  of  that  escape,  may  be  of  two 
orders — that  brought  about  by  gross  breaches  in  the  continuity  of  the 
vessel  wall,  hemorrhage  per  rhexin,  and  that  occurring  in  capillary  ve.;sels 
v.ithoiit  breach  of  continuity,  but  through  the  iustcrstices  of  the  wall, 
hemorrhage  per  diapedesin.  ( 1 )  The  former  may  be  cardiac,  arterial,  or 
venous,  and  may  be  brought  about  by  trauma,  by  disease  and  weakening 
of  the  vessel  walls,  and  by  grave  alterations  in  the  relations  of  the 
pres.sure  acting  upon  the  vessels  fr«)m  without,  and  the  blood  pressure 
within  the  vessels— whether  by  undue  lowering  of  the  ext«'rnal  pressure, 
or  undue  raising  of  tlie  blood  pressure,  or,  lastly,  by  a  combination  of 
thes'j  causes,  1.  c,  an  increase  in  blood  pressure  thn/.igh  sudden  exertion 
which  would  have  no  effect  upon  healthy  arteries  mav  lead  tf>  cardiac 
or  arterial  hemorrhage  in  one  suffering  from  disease  of  the  myocardium 
or  syphilitic  disease  of  the  aorta.  Here  may  be  noted  a  rare  order  of 
hemorrhage,  rvgiiuiul,  capillary,  and  apparently  jwr  rhexin,  that, 
namely,  of  nervous  origi:;,  seen  occasionally  in  hysterical  individuals. 
The  "stigmata"  on  the  hands  and  feet  of  religious  enthusiasts  are  of 
the  same  or-Ur. 

(2)  Hemorrhage  jicr  diapcdcu.n  occurs  from  the  capillaries  an<l  veiniles 
as  a  result  of  acti\  e  or  passive  congestion.  It  is  generally  held  that  the 
passage  of  the  blood  elements  occurs  between  the  endothelial  cells  hy 
expansion  of  the  bridges  a-.M  spaces  bet-veen  those  cells.  Impoverished 
mitrition  of  that  cndot!  .'lium  still  further  favors  the  escape  of  hloixl, 
ns  does  lack  of  support  by  surrounding  tissues.  Thus,  this  form  of 
hemorrhage  is  particularly  liable  to  occur  where  the  capillaries  are 
superficial,  as  beneath  serous  surfaces  and  in  the  lung  alveoli.  A  similar 
oozing  of  blood  may  show  itself  where  the  arterial  wall  is  thinned  and 
its  endothelium  imperfect,  as  in  false  aneurysms. 

Various  nanu^s  have  been  given  to  hemorrhages  in  different  regions; 
thus  a  cerebral  apoplexy  is  a  hemorrhage  brought  aVout  by  rupture  of 
one  of  the  arteries  of  the  base  of  the  brain,  and  its  results;  hematemesis, 
a  gastric  hemorrhage,  or,  more  accurately,  its  results,  the  escape  of 
blood  from  the  stomach  through  the  mouth;  melena,  the  discliargc 
of  blood  ])er  anum  rendere<l  black  (/ts/.a;,  f.  iiihuwi)  by  the  action  of 
the  intestinal  juices;  hemoptysis,  the  expe<torati<m  of  blood  after  i)ul- 
monary  hemorrhage;  hematuria,  hemorrhage  along  the  urinary  tract 
causing  Idoody  urine;  metrorrhagia,  hcit-orrhage  into  and  from  the 
uterine  cavity  at  times  other  than  the  menstrual  period;  menorrhagia, 
excessive  loss  of  blood  at  that  i)eriud  (/"J'',  a  month);  hematidrosis, 
bloody  sweat.  The  teruis  hematopericardium,  hematothorax  explain 
themselves;  hematocele  is  the  accumulation  of  blood  in  an>-  IhhIv 
cavity  («?/ij,  a  tumor).  \  hematoma  is  a  localized  i)rojecting,  tiiiiior- 
like  accumulation  of  blood  in  the  tissues;  petechise  are  punctate  capil- 


.*^V«i       a„awi 


%£:£«<^»i« 


HEMORRHAGE 


355 


liirv  li.inorrliiiKcs;  more  (iifl'iisc  <-ai)illiiry  licinorrhnKes  so  dose  set  that 
tli..\  tfiiil  to  run  tofietluT  art-  ecchymoses  or  suggillations ;  where  these 
li(iiM.rrha«es  are  multijile  and  siihciitaiieoiis  we  speak  of  purpura. 

General  Effects.  -Tlie  gravity  of  a  heniorrhape  depends  ujx)n  (1) 
tlif  iuniiinit  of  Hood  lost  from  the  vessels,  (2)  the  rate  at  whieh  it  is 
l(.>t  I  that  amount  whieh,  withdrawn  suddenly,  leads  to  death  may  be  lost 
MV( ml  times  over  in  recurrent  smaller  hemorrhaf,'i-s),  (:{)  the  region 
ot  h.nK.rrhage  (thus  a  hemorrhage  of  l.ut  an  ounce  into  the  brain 
siil)stjmce,  by  pressure  upon  and  olistruction  of  important  centres  and 
triKts  may  cause  rai)id  death,  where  a  pint  withdrawn  from  the  vein 
(if  all  arm  may  be  followed  by  a  feeling  of  relative  well-being).  It  mav 
!•<■  l.nd  down  that  the  normal  adult  individual  mav  suffer  the  loss  of 
tw.Mty  ounces  of  blood  without  harmful  effects,  and  of  less  than  half 
tlir  total  volume  of  blcxnl  without  necessarily  fatal  results;  women 
hiiir  ihc  loss  ol  large  amounts  of  blood  better  than  do  men. 

Tiiking  these  into  consideration  the  general  effects  of  hemorrhatre 
may  I.e: 

I.  .Sudden  death  within  a  minute  or  two,  as  after  rupture  of  the 
luart,  or  burstmg  of  a  thoracic  aneurysm  into  the  pleural  cavitv, 
IMric.irdium,  a-sophagus,  or  trachea. 

1'.  1  )<atli,  preceded  by  coliapse  and  all  the  symptoms  of  grave  cerebral 

aiicMiiM. 

:!.  (  (>llaj»e  followed  by  hydremia  and  eventual  recovery. 
I  S\  iicop(  or  temporary  cerebral  anemia  with  rapid  recovery. 
.'.  >...  disturbances  due  to  cerebral  anemia,  but,  in  cases  of  hemor- 
rliaL'K- .  xtravasation  into  the  tissues  or  cavities  of  the  bodv,  the  devel- 
HiiUK  nt  ut  a  febrile  state  due  to  difiusion  of  the  products  of  disintegration 
ot  tlif  . Mravasated  blood. 
Th.  mI-ox  e  nee.l  little  comment,  save,  perhai)s,  to  note  that  diminution 
""'  *"•;■'''";;"«  ''l«od  below  the  normal  amount  is  followed  by  a 
pa-airr  ol  fhnd  from  the  tissues  into  the  blood  vessels  so  as  to  restore 
in  a  i.w  numites  the  amount  of  fluid  within  the  vessels;  this  passage 
mnl.  r.  the   ,loo,|  hydremic.    So,  also,  secondary  to  any  considerable 
'-  .'I  I.  .).Hi  there  is  increased  activity  of  the  hematopoietic  tissues, 
•  "nH.i,,l,ly  an  increase  in  the  red  marrow  of  the  bones  (increased 
prn,lu. i,un  „t  erythrocytes).    With  repeated  hemorrhages  the  marrow 
')    |--n,r  cxha„ste<l  and  the  reproduction  of  red  corpuscles  be 
i"T  "  >,     1  |„,,s  ,„  a  case  of  vascular  papilloma  of  the  bladder  with 
11  "na  ..xt.M.d.ng  oyer  many  months,  we  have  seen  developed  a 
"    "  ■-  ,.|„.,ly  resembling  pernicious  anemia  in  every  respect,  sa.e 
iM  ,1  I,,,,.,  ot  i,uTease<l  iron  content  in  the  liver. 
Local  Effects.    The  loss  of  continuity  of  an  artery  by  deflecting 

"•;■•""'»">  It-Kl  to  at  least  temporary  lack  of  nutrition  of  the 

Pi'l.v.  In  general,  where  there  has  been  rupture  there  follows 
PHKcss  whereby  the  escape  of  blood  is  brought  to  an  end- 
I  "M'scaiK.  IS  at  all  considerable  the  blo,Ml  pressure  Lecomes 
'1^  '"«^'red,andwiththistherate  of  escape  is  Iessenc.1.  (2)  \s 


tli( 
area  r. 
a  iiati 
I  1  i  \(  I 
iirii-n 


3r.6 


TIIK  CARniOVASCCLAR  SYSTEM 


,;4        J 


in 

iil 


the  hl()0(l  oscaiM>s  tliroiigli  tlio  woiiiulod  \  osscl  into  the  tissues,  contact 
with  those  tissues,  and  their  eoa>;iilins,  iixiuees  eoaKnIution,  and  this 
in  its  turn  lias  a  hemostatic  action  which  becomes  more  complete  the 
slower  the  hlood  stream,  {'.i)  The  solution  of  continuity  of  the  vessel 
wall,  if  the  ruptun-  he  transverse,  is  followed  hy  contraction  of  the 
middle  coat,  and  diminution  of  the  vascular  lumen.  If  it  he  itnxf^i- 
tudinal,  on  the  contrary,  the  contraction  results  in  the  opening;  remain- 
ing patent.  But  in  Kcneral,  besides  (1)  the  directi(>n  of  tlie  ru|)ture,  the 
natural  arrest  of  hcmorrhape  (lei)ends  upon  these  main  factors,  (2)  the 
si/e  an<l  nature  of  the  vessel  involved,  whether  artery,  vein,  or  capillary, 
(/<)  the  force  of  the  heart  action  and  blood  pressure,  and  (4)  the  state 
of  the  blood,  whether  hyperinotic  or  hypinotic.  There  arc  those  in 
whom  a  triHinj;  contusion  with  rupture  of  vessels  of  inconslderait!*' 
size  is  followed  by  intractable  hemorrhage  endangering  life,  in  wh'im, 
for  example,  the  extraction  of  a  tooth  is  dangerous.  To  these  vi(  tims 
of  hemophilia  we  have  alrea«ly  referred,  pointing  out  the  hereditary 
nature'  of  the  diathesis  (see  p.  47).  As  to  what  is  the  exact  nature  of  the 
state  we  are  still  in  ignorance,  whether  there  is  an  excessive  development 
of  antithrombin  or  a  lack  of  kinase  or  coagulins.  It  has,  however,  JH-en 
noted  that  the  intravenous  exhibition  of  horse  or  other  blood  serum 
tends  to  arrest  hemorrhage  in  these  individtials. 

Ne.xt  as  to  the  fate  of  the  extravasated  blood.  This,  when  it  esca|)€S 
into  the  tissues,  untlergoes  coagulation;  when  it  escapes  into  cavities 
lined  by  endothelium  it  may  remain  fluid  for  some  little  time,  and  in 
this  fluid  stiite  may  undergo  reabsorption  through  the  lymphatics  both 
as  regards  its  fluid  and  its  corpuscles. 

In  j)etechiie  and  minute  hemorriiages  into  the  tissues,  through  the 
agency  of  leukocytes  the  extravasated  corpuscles  after  undergoinjr 
disintegration  may  be  completely  absorbed,  although  often  some  pig- 
ment is  left  behind,  leading  to  a  coloration  which  disappears  in  the 
course  of  weeks  and  months. 

Where  the  hemorrhage  is  more  extensive  the  following  changes  may 
occur: 

1.  Escape  of  hemoglobin  from  the  extravasated  erythrocytes  with 
hetnoglobin  imbibition  an<l  discoloration  of  the  area. 

2.  Disintegration  of  the  escaped  hemoglobin  with  production  of 
hemosiderin  and  hematoidin  (see  p.  ',V22).  The  different  stages  in  the 
disintegration  lead  to  a  scries  of  color  changes  (as  seen  in  the  fiuiiiliar 
"black  eye"). 

;}.  Absorption  of  the  pigment  and  disintegration  products  by  lenko- 
cytes,  which  may  be  found  in  the  area,  containing  pigment  ami  other 
granules. 

4.  Where  the  lieniorrhage  is  large  and  the  absorption  incmnplete 
there  may,  as  in  some  hematimias,  be  a  production  of  surrounding 
granulation  tissvie  and  eventual  production  of  a  hemorrhagic  cyst  (p. 
2!K)),  the  contents  of  the  cyst  becoming  eventually  a  colorless  m  .'•iim. 


!^&c>at«CT  »gaap  ■»- 


QVM.it ATI VK  CIIANf!RS  l\  THE  BLOOD 


357 


The  bactericidal  jxiwcrs  of  the  blood  arc  such  that  it  is  ra 'c  for  a 
111  iiK.rrhajiic  extravasation  to  become  infected  and  terminate  in  abscess 
fonniition  or  putrefacticm. 


QUALITATITE  CHANGES  IN  THE  BLOOD 

111  this  section  we  have  to  pass  rapidly  in  review  the  main  data 
(oiKrniiiiK  tise  variati<ms  in  the  plasma  and  the  corpuscular  elements 
(if  the  l)lood  and  their  relationship  to  disease. 

The  Plasma.-  We  are  but  at  a  beginniuK  "f  our  knowledge  concerning 
till'  significance  of  changes  in  the  composition  of  the  plasma.  While  it  is 
rcliitJMly  easy  to  determine  the  variaiions  in  its  main  t"«'m('^ts,  water, 
struiii  albinnin  and  serum  globulin  and  salts,  we  are  coming  to  realize 
tliiit  (Diistituents  present  in  quantities  too  miinite  to  be  isolated  by 
(•luiiii(  111  niethiMls  exercise  a  profound  influence  upon  the  Ixxly  at  large— 
(iiz.Miiis,  hormones,  toxins,  and  antitoxins.  Biological  as  well  as 
iliiiiiicjil  methods  have  to  be  invoked  in  order  to  gain  a  completer 
kiKiwInljje  ()f  this  great  medium  of  interchange  between  the  various 
ti-Mi(N  this  stream  which  is  at  once  the  mitritive  medium  and  the 
si'ucr  111'  the  body. 

.\-  .vKiirds  its  main  elements,  what  impresses  us  is  the  evidence  of 
till'  I  \i>teii(c  of  mechanisms  which  in  the  normal  state  keep  their  ratio 
txtninnliiiarily  constant,  so  constant  that,  as  A.  B.  Macallum  has 
p'liiitcil  out,  the  salts  still  retain  the  relative  proportion  characteristic 
<>t  th.it  ancestral  i)eriod  when,  with  free  connnunicatioii  between  the 
\»»\\  I  iivity  and  the  external  medium,  the  internal  tissues  were  bathed 
"II  Ihii  slightly  modified  sea-water.    Acvertheless,  in  disease  varijitions 
iiri  iii.i infest.    Thus,  as  already  indicated,  i,  condition  of  hydremia  is 
ii"I  niir  qiient,  of  increase  in  the  plasma  relative  to  the  corpu.scular 
•i"i!'iii-    with  accompanying  lower  specific  gravity.     This  mav  be 
tin  lijii  ;ilH.ut  (1)  by  actual  increase  in  the  amount  of  circulating  fluid, 
it-  in  .ii-tnietive  heart  .iisease,  (2)  by  no  in  r-ase,  but.  on  the  contra.-v, 
'I''  r.  iH  111  the  ti.tal  amount  of  circulating  fluid,  as  after  severe  hemoV- 
\\iiiii  with  loss  of  blood  the  plasma  undergoes  a  compensatorv 
h,  teiidnig  to  maintain  its  volume.    A  similar  relatiM-  hydremia 
;i«  ti  ristic  of  conditions  of  grave  anemia  brought  about,'  not  by 
■!'a^e,   i)iit   by  intrava.scular  deatli   and   disintegration  of  the 
■'  vtes  (;;)  by  increase  in  the  .salts  of  the  blood  tending  to  attract 
lii'l.  SI)  that  the  hypertonic  state  of  the  plasma  may  be  reduced 
niiiii.    This  process  has  been  invoked  to  explain  the  hydremia 
'  iri>,  \n  will-  li  ti.ea'  are  evidences  of  increased  retention  of  chlor- 
'  system,  th()tii,ii  here  also  the  loss  of  the  proteins  of  the  blood 
iiiti)  the  urine  may  be  a  fact(,r  of  .some  importance.    Thus. 
\  <lrt  inic  state  of  the  blood  may  be  encountered  (1)  in  obstruc- 
'!i'l  lung  aisease,  (2)  in  kidney  disease,  more  particniarlv  the 
iiiliyniatous  form,  (.])  after  severe  hemorrhages,  (4)  in  condi- 


liiiiii 
i>  ( h 
llrili! 
IT,\  I  i 

iiinri 

tl.ll 
llf  I,, 
illl- 

hv  , 

!,ri,. 
ti\, 

ari;i 


.''K»B«MlK>p-S 


»*l.»k.>iSV«-Jf. 


358 


THE  CARDIOVASCULAR  SYSTEM 


tioiis  ns.s(H*iutt><l  with  (lrstruoti(»n  of  the  r<  <l  ''orpusch's,  sever*'  infections, 
aiivanced  inaliKiiariey,  anil  pemicicnis  anemia 

Of  the  proteins  of  the  phisnia  (a^  contras',e<l  with  IiIcmkI  serum)  wi 
have  already  calletl  attention  to  tne  eon<lition:-  of  hyperinosis  ami 
hypinoaifl,  (hu'  presumably  to  diUVrenees  in  the  ratio  hetwt'cn  fihrin- 
ogen  and  fibrin  ferment.  Unt  in  the  generality  of  cases  it  vcnild 
ap|K>ar  that  we  have  to  deal  not  so  much  with  an  excess  or  <lefi«  unc y 
of  the  substratum  to  be  acted  ujxm,  the  fibrinogen,  as  of  the  kinase  ain! 
its  concomitants,  the  calcium  salts,  etc.  It  is  the  rat'  of  cuH^rulntion 
rather  than  the  amount  of  fibrin  that  shows  the  greatest  varmiiDn. 
There  are,  however,  indications  that  in  certain  conditions  the  amount 
of  fibrinogen,  and  so  of  fibrin  produced,  is  delinitely  below  the  normal. 

Of  the  salts  of  the  plasma  (sodium  salts,  chlorides,  phosphates)  this 
may  be  said,  that  they  play  a  part  in  the  solution  of  the  proteins  and 
are  normally  present  in  such  relationships  that  the  plasma  is  definitely 
alkaline.  Reduction  of  the  alkalinity  (acidosis,  p.  WJ)  is  followed  hy 
the  gravest  metabolic  disturbances. 

Lipemia. — From  the  normal  plasma  there  can  always  be  isolated  a 
minute  quantity  of  fat,  but  occasionally  we  meet  with  an  extraordinar)- 
increase  in  this  fat,  a  condition  of  lipemia.  As  in  milk  it  is  present  in 
fine  globules  in  the  form  of  an  emulsion.  The  amount  may  be  such  that 
the  serum  a.ssumes  a  distinctly  milky  appearance.  We  know  little 
regarding  the  causes  leading  to  the  coiulition,  save  thiit  it  is  encountered 
in  diabetes  and  other  diseases  characterized  by  defective  oxiflation  and 
increased  carbon  dioxide  of  the  blood,  phosphorus  poisoning,  severe 
anemias,  pneumonia. 

The  Red  Corpuscles.  Variation  in  Number. — We  have  already  laid 
btress  upon  the  t'i<  r  ili!'  moderate  increase  or  decrease  in  the  niiiulH'r 
of  erythrocytes  per  cubic  millimeter  gives  us  no  sure  infomuitinn  unless 
at  the  sanu  time  we  detennine  the  total  volume  of  blood;  such  change 
may  be  brought  about  bv  concci\tration  or  dilution  of  th<!  blood  jjlasnia 
as  wrl!  as  i)y  actual  incnase  or  decrease  in  the  number  of  v'ireulating 
corpuscles.  There  may  be  an  apparent  great  increase  in  the  red  cells  in 
cholera  nsiatica.due  to  draining  away  of  the  fluid  from  the  blood,  or,  on 
the  other  hand.  :in  actird  polycytliemia.  A  great  increase  in  the  number 
of  red  iorpusclo  is  seen  in  those  living  at  high  levels,  and  this  without 
recognizable  diminution  in  the  total  volume  of  the  blood.  What  is  the 
cau.se  has  not  surely  been  determined.  Even  in  a  balloon  ascent  to  an 
.iltitude  of  several  thoiis  uid  feet  an  increa-se  from  the  normal  5,(1(10,000 
to  S,.")(K»,(HM»  has  been  recorded.  .\  similar  increase  has  been  ree(i;,'nize<! 
in  iuiinials  made  to  breathe  carbon  monoxide.  This  suggests  that  tin 
change  is  adaptive,  due  to  increased  demand  for  oxygen,  and  that  it  is 
brought  about  by  an  increased  outpouring  of  erythrocytes  Inun  the 
bone  rnarn  w. 

A  pati 'ii,.;^it'al  pjdycythemia  has  been  recojded  by  several  observers, 
U'u  >nnccted  witl.  cliangc  in  altitude,  blood  counts  affordiiii,'  from 
S,i)U(),(KH)  to  1 1,0*  :;•  'JIM)  corpuscles.   There  is  often  an  associateil  enlarge- 


.£-!»-•  J^i?" 


THE  RED  CORITSCLES 


3:)9 


in.  lit  of  thf  splet'i.,  aii.l  a  <Iiisky,.r  cyuriotic  uppraranc-e  of  tlio  skin,  with 
,it  |K.st  mortem,  pr.  M-mr  of  al.iin<lant  ml  marrow.     The  <ause  of  the 
M,  itioi,  IS  practu-ally  iii.k.iowi..     lV«th  oftn,  .Kriirs  within  a  frw 
«irk         n-coKiiitioii  of  the  state.  altlu.iiKh  a  few  eases  of  return  t(. 
iitiriiiiii  iijivi-  iH-eii  m»te(l. 

VartattOM  in  Sli..  Where  there  is  .listurlmiiec  in  the  produetion  of 
r,,l.  urpi.seles  asmseeon.lary  a.ul  perni.ions  anemias.<rrtain  eorpuseU-s 
M.ay  attam  hirge  size  (megalocjrtes),  with  a  .lia.neter  of  from  10 
to  JOm  m  plaee  of  the  normal  7  to  S.-V-  In  the  same  .-on-litions  we 
n.ii.v  also  enejMinter  eells  that  are  abnormally  >tnall  (microcytes).  alone 
uithcorpuseles  exhibiting  ^reat  variation  in  shape  (poikilocytes.  froin 
.-■/:/((;,  various). 

VariatlOM  In  Structure  and  SUIninf  E«actlon«.-A  stiaK-  of  the  red 
MMrruw  shows  that  tlie  red  corpuseles  originate  from  muleated  eells 
.rvthroblasts-by  a  proeess  ..f  gradual  shrinkage  of  the  m.eleus.  with 
<li-.  liar,!;.-  of  mieleoli  or  nueleolar  matter  into  the  evtopjasm.  wliieh  at 
fir>t  Mattered  mnnisses,  gradually  dilfuses  evenly  fhronjch  the  whole 
<M"l'l;'~'i'.  In  disease  we  may  eneounter  various  modifications  of  the 
n.riMMJ,..  wlueh  represent  stages  in  their  development  and  in.lieate. 
t  .r.  tnn  an  m.reased  activity  of  the  marrow,  with  |.remature  dis.harge 
"!  '  H.  .■orpuseles.  Ue  thus,  at  times,  e..eonnt.T  nucleated  red  cor- 
PUM  Irs  ,n  the  lorm  of  megaloblasts,  large  cells  with  large  pale  nuclei 

III.  .Mrlipt  stage),  normoblasts,  which  are  hemoglobin-containing  cells 
'  t  -inriiial  Mze,  but  nucleated,  and  other  cells  .xl.ibiting  polychromatol 
pluha.  .rrtam  corpuscles  taking  on  a  more  basic,  i)urpliil.  stain  Hv 
'"""laiiowsky  s  stain  or  modifications  of  the  same  this  is  characteristie 
:'l  MiiiMatnre  erythrocytes.  The  '-stippling"  of  tlu-  rinl  eorpusch-s,  seen 
I"  ""'<•  eases  of  leac    poisoning,  may  also  indicate  an  incomplete  con- 

.TMui,  .,(  discharged  nucleolar  matter  into  hemoglobin,  and  mav  also 

"  •  "I'lHc  ot  immaturity.  As  regards  irregular  staining,  it  must  be 
'M...I  tliat  tins  may  also  be  met  with  in  eases  of  reeognizable  degen- 
•ra  inu  .,t  the  corpuscles  (r.  ;/.,  in  early  thrombi). 

Oilur  .•i,.ar  evidences  of  <lisintegration  are  seen  in  the  con.litions  of 
pUsmonhexis  and  plasmoschisis.     The  former  is  the  development  of 

'■^li  i  i;    at  the  perii)hery,  with  progressive  liberation  of  peripheral 

Mo  ml, ., ,,  varying  size.    The  latter  is  the  rapid  breaking  up  ..f  the  wliole 

'!>,  "'  fl'V  corpuscle  into  small  gh.bules  from  ^^hiell  the  hemoglobin 

|-  .  •..:  -hMliarged  so  that  as  they  separate  they  are  searce  .listin- 
«ii.-!„im|c  tr.)ni  blood  platelets. 

Variations  fa  Hemoglobin  Content.-There  ma^'  be  great  variation 

-lor  in.lex  of  ti.e  blood,  i.  r.,  the  ratio  of  the  hemoglobin  ],er 

,  •■     \",'^  ''•.  f*>r  example,  found  increased  in  per..icious  anemia. 

■  in  c!,|„ro-,s.     llu-re  may  be  both  a  reduction  in  the  henio- 

!  -".  uce.'    as  in  the  latter  case-a  defective  eonversion  of  the 

•■"'t. .  „|  tne  erythroblast  into  hemoglobin,  and,  on  the  other 

''illusion  ol  the  hemoglobin  out  of  the  corpuscle  or  hemolysis 

-  numerous  agencies  which  can  bring  about  hemolvsis  both 


Ih  I 
ri'ilui 

iiikI, 
lian  :. 


W^^T^I^imSy^^ 


MICROCOPY    RESOLUTION    TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No.  2i 


1.0 


I.I 


«-  IM     III  2.2 
J-    1 3.,      i^ 

"    l"    lllll^ 


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1.25 


1.6 


^     APPLIED  IIVHGE     Ir 


'•-'"■1     ioV     Mjin    SiffP' 

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'-1^='..= 

-•■;hesler,    Ne*    v    .-          U609 

U->A 

^^'—         ■ 

"6)    ".82  -   03;/           p^ij"e 

^'6)    .^88  -  b98^       -ai 

360 


THE  CARDIOVASCULAR  SYSTEM 


ti 


within  the  vessels  and  in  the  test-tulie:  cold  (as  in  paroxysmal  heino- 
gl()l)innria),  "leat  (as  in  hums),  tiie  sera  and  tissue  cxtrae'ts  of  animals 
of  «)ther  species,  and  sometimes  of  those  of  the  same  species,  experi- 
mentally i)roduced  hemolytic  sera  (p.  163),  certain  bacterial  toxins 
(which  possibly  explain  the  anemia  of  many  infectious  diseases),  notably 
those  of  streptococcus,  B.  coli,  pyococcus  aureus,  pueumococcus; 
vejietable  products,  such  as  ricin  and  amanita  (mushroom)  poison. 
In  addition  many  chemical  agents  bring  about  this  diffusion  out  of 
hemoglobin  an<l  "laking"  of  the  blood,  notably  pyrogallic  acid,  glycer- 
ine, potassium  chlorate,  and  toluylenecliamin.  And  by  employment  of 
one  or  other  of  these  agents  we  can  materially  reduce  the  number  of 
circulating  erythrocytes.  The  red  corpuscle,  that  is,  when  it  has  lost 
its  hemoglobin,  lias  no  power  to  reproduce  it,  and  .so  is  rendered  largely 
useless.  Its  stroma  is  removed  by  the  agency  of  the  spleen.  Thus,  by 
inoculating  rabbits  with  repeated  non-lethal  doses  of  B.  coli  (Charlton), 
or  by  similar  doses  of  ricin  (i3unting),  the  number  of  erythn  jvtes 
becomes  reduced  to  1  ,()()0,()()()  or  less  per  c.mm.,  and  conditions 
(including  poikilocytosis)  closely  simulating  pernicious  anemia  are 
produced. 

Secondary  Anemias.— When  we  can  determine  what  appears  to  be 
an  adequate  cause  for  the  reduction  in  the  total  number  of  corpuscles, 
we  speak  of  a  secondary  anemia.  This  may  be  &cute,  as  after  profound 
loss  of  blood,  ])otassium  chlorate  poisoning,  and  severe  infections,  or 
chronic,  as  after  recurrent  small  hemorrhages,  in  splenic  anemia,  cancer, 
and  exhausting  diseases,  leatl  poisoning,  intestinal  i)arasites,  etc.  The 
longer  continued  the  destruction  or  loss  of  red  corpuscles,  the  greater 
the  strain  upon  the  marrow  and  bloo<l-forniing  organs,  with  the  result 
that  nucleated  and  other  premature  and  imperfectly  formed  erythro- 
cytes are  apt  to  appear  in  the  circulating  blood  imtil  finally,  as  in 
those  afflicted  with  the  fish  tapeworm  (Dibothriocephalus  latu-  .  or 
in  some  cases  of  cancer,  the  blood  picture  is  indistinguishable  tn.ia 
that  of  pernicious  anemia. 

Pernicious  (or  Addisonian)  Anemia.— This  affords  a  very  character- 
istic picture.  The  victim  has  a  peculiar  lemon  yellow  color,  is  apt  to  be 
flabl)ily  fat,  exhibits  progressive  muscular  weakness,  with  weak  heart 
action,  a-hlorhydria,  or  absence  of  free  acid  in  the  gastric  juice,  jukI 
other  digestive  disturbances,  diarrhcra,  etc.  There  may  be  one  or  two 
remissions,  i)ut  with  very  rare  exceptions  the  course  is  fatal  within 
jess  than  two  years  The  blood  condition  is  striking:  marked  reduction 
in  the  number  <)f  erythrocytes,  it  may  be,  down  to  o(X),()0()  j)er  c.iiiin.: 
presence  of  poikilocytosis,  with  macrocytes,  microcytes,  and  nucleated 
red  corpuscles.    The  color  index  is  increase(l. 

At  autopsy  the  most  marked  features  are  the  bright  yellow  color  of 
the  body  fat,  the  small  amount  and  thin,  watery  character  ol  the 
blood,  the  pallor  and  bloodlessness  of  all  organs;  the  fatty  degcrura- 
tioii  of  the  heart  inuscle;  the  presence  of  increased  iron  in  the  liver 
demonstrated  by  Quincke's  (Prussian  blue)  or  Perl's  (sulphide  ot  iron) 


PERNICIOUS  ANEMIA-CHLOROSIS  301 

U>t,  and  evidences  of  hyperplasia  of  the  red  marrow  of  the  bones 
In.iuently  there  is  an  accompanying  atrophic  gastritis,  and  evidence 
nt  interference  with  the  sensory  tracts  in  the  lower  part  of  the  cord. 

1  liese  various  conditions  suggest  the  continued  action  of  a  hcmolvtic 
ti.Niii  ot  gastro-mtestinal  origin,  leading  to  excessive  destruction  oi'the 
n.l  corpuscles,  increase  m  hepatic  iron,  and  increased  but  imperfect 
(d.npensatory  production  of  corpuscles.  The  increase  in  hepatic  iron 
lor  example,  is  a  result  of  hemoglobin  disintegration;  the  pigmentation 
ot  the  fat,  a  result  of  modification  of  the  hemoglobin  liberated  in  the 
.  in  ulating  blood.  Whether  the  fatty  degeneration  of  the  heart  muscles 
IS  (it  toxic  origin  or  due  to  deficient  oxidation  is  uncertain. 

The  cause  of  the  hemolysis  is  still  undetermined;  there  mav  be  more 
tlian  one.  Prom  the  frequent  association  of  pyorrhoea  alveolaris,  a  low 
t..rin  ot  suppuration  involving  the  sockets  of  the  teeth,  Hunter  inclines 
to  the  view  that  a  secondary  chronic  streptococcic  gastritis  is  the 
esstntial  cause;  one  of  us  (Adami)  has  suggested  that  we  deal  with  a 
sul.inlcction  by  means  of  hemolytic  intestinal  bacteria  of  the  colon 
Kroii|);  Herter  would  implicate  the  excessive  proliferation  of  tht  B 
\H.lm  in  the  lovver  intestine.  Based  upon  the  close  resemblance 
liotw.ci  the  clinical  picture  and  post  mortem  appearances  in  man  and 
tlM>M.  (,t  surra  and  dourine  in  the  horse,  the  latest  hypothesis  is  that 
«<•  .l.al  with  a  condition  of  trypanosomiasis.  The  riddle  has  still  to  be 
solved. 

Aplastic  Aaemia.— Rarely  there  is  encountered  an  extreme  anemia 
.'""■npanied  not  by  hyperplasia,  but  by  an  hypoplasia  of  the  bone 
Miiirrmv  and  hemopoietic  centres.     There  is  great  reduction  in  the 

".' '■'■  "f  '■«'•,  corpuscles,  abr^ence  of  normoblasts  and  megaloblasts 

'  immature  erythrocytes),  low  color  index.  Poikilocvtosis  is  not  marked 
lymphocytes  are  in  good  number,  but  leukocytes  (polvnudears  and 
to>nM>|)hiles)  fewer  than  normal.  Instead  of  increase  in  red  marrow 
tli.ro  IS  reduction,  its  place  being  taken  bv  fat  cells. 

Chlorosis.-Chlorosis  is  an  anemia  of\  different  order  affecting 
>oiinir  a.lult  females;  its  presence  in  young  males  is  so  rare  that  many 
"<>i>  Its  existence.  There  is  a  characteristic  pallor,  the  "green  sickness" 
"I  l.li/..il.ethan  writers,  lassitude  with  weakness  following  upon  slight 
«^'rllnM  (lyspopsia  and  capricious  appetite,  gastric  acidity,  constipa- 
'loii  .111(1  attacks  of  palpitaticm. 
'I '  <  I'lood  exhibits  definite  hydremia  with  corresponding  reduction 
N_. lumber  of  erythrocytes  per  c.mm.  What  is  most  marked  is  the 
r-'iM'  ti(,„  „i  the  hemoglobin,  so  that  the  color  index  averages  0..5,  and 
'  as  l(.w  as  0.1.  The  good  effects  that  follow  the  proper  exhil)ition 
I  Hi^gost  that  imperfect  production  of  hemoglobin  is  the  essential 
'  \N  hat  leads  to  this  we  do  not  know,  although  several  clinicians 
11(1  stress  upon  constipatio.i  and  the  good  effects  that  follow  a 
"t  laxatives,  suggesting  intestinal  intoxication  as  the  underlving 
nthers  see  a  relationship  between  the  sex  of  those  afft' ted 


lll;i\ 
of  ir 
tV;il 

Clill! 
CM  11^ 


■ 


302 


THE  CARDIOVASCULAR  SYSTEM 


■f .. 


n 


m-  i 


and  between  disturbances  of  the  menstrual  function  and  thtse  blood 
disturbances. 

The  Leukocytes.— Before  proceeding  to   'scribe  the  changes  that 
occur  in  the  leukocytes  it  is  necessary  to     a.sifv  these  and  to  have 
some  idea  as  to  the  relationship  of  the  dif..'rent  forms.     Now  this  is 
not  an  easy  -natter,  and  that  because,  despite  abundant  research,  there 
IS  still  active  controversy  regarding  many  points,  and  to  discuss  the 
pros  anu  corus  would  occupy  many  pages.    We  can,  therefore,  but  give 
dogmatically  our  own  opinions  regarding  these  matters,  stating  franklv 
tiiat  these  represent  one  view,  and  that  they  are  liable  to  revision.'     ' 
Briefly,  we  have  to  distinguish  between  the  circulating  white  cor- 
puscles and  those  found  outside  the  vessels  and  in  the  tissues,  certain 
wandering  cells  being  found  in  the  one  region  and  not  in  the  other    We 
can  further  distinguish  between  those  white  corpuscles,  or  wandering 
cells  which  originate  from  myeloblasts,  those  that  originate  from 
lymphoblasts  and  lymphoid  tissue,  and  those  originating  from  endo- 
thelial and  other  connective-tissue  elements.      I'he  trend  of  recent 
observ;      ,ns  is  to  approximate  more  and  more  the  last  two  groups, 
ihe  dilliculties  in  making  a  classification  depend  essentiallv  upon  this, 
that  the  earliest  and  simplest  stages  of  developing  cells' show  prac- 
tic-ally  no  differentiation,  and  thus  it  becomes  a  matter  of  extraordinarv 
difhculty  to  trace  back  the  different  forms  of  cells  to  their  origins,  par- 
ticularly when  in  the  hemopoietic  system  the  different  orders  of  ceils 
are  apt  to  originate  s.de  by  side  and  not  from  different  isolated  centres. 
Forma  of  Leukocytes —Vie  may,  however,  distinguish  the  following 
main  forms: 

Of  myeloblastic  origin  (granular  leukocytes):  (1)  the  polymorpho- 
nuclear, polynuclear,  or  neutropWle  cell.  This  is  the  commonest  white 
corpuscle  of  the  circulating  blood,  constituting  in  general  more  than 
bo  per  cent,  of  the  white  corpuscles  present  in  normal  blood.  In  its 
cytoplasm  are  fine  granules  which  stain  with  n.utral  or  more  accurately 
weakly  acid  dyes.  It  is  the  form  in  greatest  abundance  in  acute  inflam- 
mation, and  is  thus  the  typical  pus  cell.  The  nucleus  is  character- 
istically lobate,  so  that  under  low  power  the  cell  appears  to  be  multi- 
nucleate. It  is  actively  phagocytic,  particularly  for  bacteria.  It  rarely 
shows  evidence  of  r.itosis  in  the  blood  stream,  or  again  in  the  tissues 
at  the  site  of  inflammation.    It  1ms  nothing  to  do  with  tissue  formation. 

The  Eosinophile.— This  is  of  the  same  size  as  the  former,  most  olteii 
'ts  nucleus  is  coarsely  lobate  or  horseshoe-shaped.  In  the  cvtoplasm 
are  granules  much  coarser  than  those  of  the  former,  and  these  take  an 
intense  stain  with  eosin  and  other  acid  aniline  dves.  It  also  mi^'rates 
out  of  the  vessels  in  the  early  stage  of  acute  inflammation,  but  is  soon 
overpassed  in  number  by  the  polynuclears,  while  again  it  is  foiiinl  in 
the  tissues  in  fair  numbers  in  certain  forms  of  subacute  inflanimalion. 

'  A  ftUler  discussion  of  tho  subject  will  be  found  in  the  small  work  on  •'Iiithmma- 
edUion"  ""*"      """  ('^'^'""'^-    (Macmillan:  I^ndon  and  New  York,  f.mrth 


LEUKOCYTES  AND  LYMPHOCYTES 


363 


III  normal  blood  this  form  is  present  in  but  small  numbers  (about  3 
ptr  cent.).  It  is  abundant  (10  to  50  per  cent.)  in  many  forms  of 
helminthiasis  (parasitic  worms),  in  certain  cases  of  chronic  skin  disease, 
etc.  Only  rarely  is  it  observed  to  act  as  a  phagocyte.  Studies  made  on 
tlii-  frog  and  other  animals  show  that  these  cells  can  discharge  their 
j;Taiiiiles,  which  are  of  nucleoproteid  nature.  The  cells  seem  thus  to 
have  certain  excretory  functions.  Opie  has  noted  that  during  the 
<  nurse  of  certain  acute  peritoneal  infections  the  eosinophile  disappears 
liirKcIy  from  the  peripheral  circulation,  but  may  be  found  accumulating 
III  the  mesenteric  and  other  vessels,  and  there  undergoing  migration. 

The  Lymphocytes.— The  typical  lymphocyte  is  distinctly  smaller 
f  hull  the  preceding  form,  possessing  a  relatively  large,  spherical,  deeply 
>taiiiing  nucleus,  with  a  relatively  inconsiderable  surrounding  layer  of 
Idioplasm.  This  form  of  cell  is  but  slightly  amoeboid.  It  is  not  ob- 
X  r\  ed  to  be  phagocytic.  In  inflaramatory  conditions  it  is  found  more 
partKularly  accumulated  around  the  vessels.  There  is  still  doubt  as  to 
wlicthiT  these  accumulations  are  the  result,  in  the  main,  of  migration, 
or  are  due  to  proliferation  of  preexisting  lymphocytes  of  the  region.' 
(Marchand.)  In  subacute  and  chronic  inflammation  {e.  g.,  tubercu- 
losis) this  is  the  preponderating  type  of  cell  present.  In  the  blood  stream 
111  pathological  conditions,  what  are  known  as  large  lymphocytes,  one 
jonii  of  "large  mononuclear,"  may  be  encountered;' these  represent 
miniature  lymphocvtes.  In  the  tissues  in  cases  of  subacute  inflammation 
the  small  lymphocytes  give  origin  to  cells  of  larger  size,  with  excentric 
iHi<  lens  and  a  somewhat  polygonal  cell  body  of  fair  size,  the  vlasma 
nil  ('p.  132). 

Mast  Cells.— These  cells,  rare  in  the  normal  blood,  may  be  occasion- 
:illv  ciicountcred  in  pathological  states,  such  as  leukemia.  They  are  of 
hiir  size  and  possess  abundant  granules  which  take  a  basic  stain  and 
iirc  so  large  that  they  may  be  taken  for  clusters  of  nu'crococci.  The 
'iiKicus  IS  generally  degenerated.  Whether  the  mast  cells  in  the  tissues 
iirr  ,,t  the  same  origin  as  those  in  the  blood  has  not  been  absolutely 
'i'  t'  riiiiiied,  but  here  they  may  take  on  motility,  and  their  path  may  be 
tr.i;|i  occasionally  by  the  granules  which  they  have  shed.  In  any 
|i"-iti()n  tlicy  are  comparatively  rare. 

HyaUne  Cells.— Cells  having  a  large  body  and  an  oval,  pale  staining 
[iji'l''us,  constituting  "large  mononuclears,"  are  encountered  in  the 

'' '  '"  small  numbers,  and  there  are  difficult  to  distinguish  from  the 

'•"  -'   lymphocytes  already  described.    Their  cytoplasm  is  free  from 
;;'•■!;  'lies.    A  similar  type  of  cell  is  seen  in  conditions  of  inflammation  of 
;'<ritoiieal  cavity,  and  here  clearly  some  at  least  of  these  cells  are  of 
tiithal  origin,  derived  from  the  lining  endothelium  of  the  serous 
I '  <s.    It  IS  possible,  therefore,  that  the  intravascular  form  originates 

[ y'^'  vascular  endothelium.    The  macrophages  of  the  sinuses  of  in- 

iii'    fl  lymph  nodes  are  of  this  order.    This  type  of  cell  is  phagocytic, 
'i'  ^     rthe  bacteria  of  acute  dise.is.-,  hut  for  other  cells  and  their  debris, 


t!, 
ei 
su 


3G4 


THE  CARDIOVASCULAR  SYSTEM 


a.ul  it  is  ^rf.KTHllv  held  that  it  is  capuMo  ..f  becoming  fihrohhistic  an.! 
so  ot  Iviulwfi  to  thf  tormation  of  coniurtivr  tissue. 

Leukocytosis.--  The  presence  of   an  excessive  number  of   any  one 
or  more  ot  the  above  forn.s  in  the  bio,«|  constitutes  a  conciitL.  of 
leukoc.vtos.s.     We  distnmuish  thus:     («)  i.oiynucIear  h-ukocvtosis  or  a 
iH'Utrophiha,  (b)  eosnioi)hilia.  (r)  iymphocvtosis,  and  (V/)  mveloc\tosis 
or  the  presence  of  aberrant  or  immature  forms.    Leukemia"  is  a  'condi- 
tion ot  excessive  hnikocN  tosis  where  the  number  of  leukocytes  exceeds 
1.)  ()00  per  cubic  milhmeter.     The  number  of      ukocvtes  of  various 
orders  present  in  normal  blood  is  in  the  neighl)orhood  of  "olHW  per  c  mm 
but  there  may  be  a  considerabh-  |)hysioloj,Mcal  variation.    Thus  voung 
individuals  exhibit  a  well-marked  relative  leukocytosis  of  12,m  to 
lo,(K«)  .lurinR  the  first  week  of  life,  of  1().(HM)  to  12.00()  during  the  first 
ten  years.    l„ward  the  time  of  parturition  in  the  female  the  number  is 
apt  to  reach  lo,(M)()  to  2(>.(KM).    .\fter  a  rich  protein  meal  there  occurs 
a  nmderatt' alimentary  leukocytosis.      I)  ring  the  last  hours  of  life  a 
terminal  leukocytosis  is  generally  to  be  recognized. 

Polynuclear  Leukocytosis  is  iliet  with  in  iuflammatorv  and  manv 
intectious  conditions;  not.  however,  in  all,  for  it  is  absent  in  tvnhoid 
malaria,  and  the  more  ordinary  type  of  chronic  tuberculosis  and  lepro.v 
save  where  there  is  secondary  infection.  So,  also,  it  is  wanting  in  measles' 
mumps,  and  in  most  cases  of  influenz.  It  is  very  pronounced  in  pneu- 
monia, where  there  may  be  a  leukocytosis  of  even  100,()0(),  with  % 
per  cent. ,..  .>o  ynuclears.  Suppurative  disease  and  local  and  generalized 
disturbances  (iue  to  pyogenic  organisms  exhibit  this  tvpe  of  leuko- 
cytosis. Jt  IS  of  note  also  that  in  states  characterized  'bv  grave  dis- 
turbance of  the  liver,  and  wh.ere  there  is  a  breaking  down  of  tissues,  as 
in  tlie  later  stages  of  carcinoma,  this  form  shows  itself.  Antipvretics 
and  salicylates  induce  a  moderate  grade. 

Eosinophilia  is  seen  in  many  difl'erent  forms  of  helminthiasis  (p  <)0) 
in  many  irritative  skin  diseases,  accompanying  myelogenic  leukemia,  in 
bronchial  asthma,  hay  fever,  and  allie.1  conditions  of  so-called  idio- 
syncrasy in  somr  post-febrile  states,  and  in  a  varietv  of  conditions  it 
IS  difhf  lit  to  correlate. 

Lymphocytosis  is  fr.>c|uent  in  > oung  children,  particularly  where  there 
are  gastro-intestinal  disorders;  it  may  be  noted  that  in  the  voung  there 
IS  a  relatively  great  development  of  the  lymphoid  tissue  of  the  bodv.  and 
especially  ot  the  intestinal  area,  and  irritation  of  the  Ivmph  nodes  is 
accompaniec  by  a  greater  .lischarge  of  lymphocytes  into  the  blood.  \ 
similar  lymphocytosis  is  f.nin.l  in  iidults,  where  there  are  enlarged  Ivnipli 
nodes.  With  whooping-cough,  lymphocytosis  is  so  marked  as  to  he 
pathognomonic.  In  scurvy,  rickets,  sclerosis,  and  debilitating  discMM.  a 
lymplKK  ytosis  ot  moderate  grade  is  frequently  noticea5)le. 

Leukemia.  -Leukemia  is  a  disease  characterized  by  the  voidi'mal 
I)resence  ot  an  t\ces<  of  circulating  leiikoc\ tes— of  more  than  l.'.ini" 
per  cubic  millimeter,  although  generally  in  the  hundreds  of  thousnuis. 
Ifie  state   is  characterized   by   progressive  weakness  and  associ.iud 


*■    'M;ll      [-  i.-i,  I 


J;ii*: 


l^lpi 


1^ 

I  j 


LEUKEMIA 


365 


iih.rnia  proptT,  usually  with  a  grnitly  t'nlarn;fil  ■  plt-in.  Tli«rc  arc,  how- 
1  \tT,  two  types— the  myelogenous  or  uivelohlastic  aiul  the  lymphatie. 
Myelogenous  Leukemia.-  This  form  is  seen  most  often  in  early  aWuit 
lit( ,  and  more  often  in  the  nuile.  The  underlying  feature  is  an  alHTrnnt 
li.\  IH-rpIasia  of  the  hlood-formiu):  tissues.  The  hone  marrow  is  always 
.illVcted,  showinj;  an  excess  of  gray  nuirrow,  in  which  ahundant  cells 
(iiii  he  found  exhihitinj;  transitional  stages,  from  myeloblast  to  nnelo- 
(,\tf,  to  the  neutrophile  leukocyte.  There  is  an  associated  increased 
ill  M'lopment  of  eosinophiles,  evidence  of  ii'.creased  activity  also  in  the 
liroductioii  of  red  corpuscles,  with  increase  in  the  number  of  mega- 
r;iry(>cytes. 

'Pile  spleen  also  reverts  to  the  condition  seen  liefore  birth,  and  presents 
indications  of  active  formation  of  myelocytes.  The  organ  may  attain 
;iii  iiiormous  size.  There  may  be  similar  indications  of  mvelocvte 
tnrniation  in  the  hver.  In  all  these  areas  there  is  but  slight  indication 
<>l  111  increase<l  activity  of  the  lymphoid  tissue  proper.  The  most 
Mriking  ('hange  is  seen  in  the  blood,  where  there  may  be  an  extraordinary 
iiK Tcasc  in  the  number  of  white  corpuscles,  varying  from  (iO.OOO  to  as 
iMiiii,\  as  l,.'i(»(),(KK).  The  greatest  increase  is  in  the  immature  granule 
irlls  „r  myelocytes,  which  may  compose  half  of  the  total,  the  neutro- 
I'liilis  or  polynuclears  constituting  almost  the  other  half.  There  is 
i;i  iiiraily  a  pronounced  eosinophilia,  some  increase  in  the  number  of 
inii>t  cell-,  and  the  lymphocytes,  although  relatively  in  small  numbers, 
n re  present  in  greater  ntunbers  than  in  health.  'With  this  there  is 
ii  'li^tiiict,  though  not  an  extreme  increase  in  the  number  of  red 
«'>ri.iis<Ies.  Tnese  large  and  abundant  leukocytes  tend  to  clog  the 
•  Mpiilaries  of  organs,  and  this,  with  the  reduction  in  the  number  of 
■■"'  "-n)"  •  "  explain  the  dyspnoea,  general  bodily  weakness, 

^111.1  \\a>,ti  ..  •  ire  features  of  the  disease,  as  again  the  epistaxis, 

■■'""■'''  ■'-  liemorrhages.     Associated  with  the  increased  pro- 

'InrtK.n  there  ..e  evidences  of  increased  destruction  of  the  leukocvtes, 
111'  il>l.\  an  ixce.ssive  discharge  of  uric  acid,  which  we  assume  to  be  due 
t.-  till  disintegration  of  the  nuclei  of  these  cells.  The  disease  is  chronic, 
i.i  tin-  troni  a  few  months  to  several  years  after  its  first  recognition. 

Lymphatic  Leukemia.— This  also  occurs  in  young  adult  life  and  mainly 
"I  '' ••  male,  although  found  at  all  ages.  In  young  people  the  disease 
t' !!  I  tu  have  an  acute  onset  and  course.  Here  not  the  spleen  but  the 
i>ii  111  glands  are  most  involved.  The  symptoms  and  phvsical  signs 
iirr  tlurwisc  much  the  same  as  in  the  other  form,  and  blood  films  show 
■  t  excess  of  lymphocytes  (see  plate)  of  typical  shape,  with  large 
iiiinmg  nucleus  and  small  rim  of  cytoplasm.  In  the  more 
lirni  they  are  of  more  atypical  and  embryonic  type,  resembling 
IK'  lyniphoblasts,  and  showing  a  less  deeply  staining  nucleus 
-  'liar  shape,  with  relatively  abundant  cytoplasm. 
!  liiT  all  these  cells  are  lymphoblastic  is  a  matter  of  present  debate. 
-^".■eMtly  been  shown  that  the  presence  of  Altmaim's  granu'es  in 
tins  order  is  not,  as  Schridde  held,  a  positive  indication  of 


: 


'^i 


w^ 


366 


THE  CARDIOVASCULAR  SYSTEM 


..  1 


11' 


Ij'mphohlastic  oriKin,  for  such  Kruiiulfs  may  also  he  detected  in  myelo- 
blasts. Thus  it  is  quite  i)ossihle  that  there  exi-*ts  an  acute  leuken>ia, 
due  to  excessive  atypical  (h-  rinpment  of  the  myelocytic  elements, 
indistinguishable  by  present  methiKls  of  rc:.cnrcli  from  the  acute  lym- 
phatic form.  Or,  expressed  otherwise,  there  may  l)e  an  acute  leukemia 
characterized  by  the  overgrowth  and  liischar.'te  into  the  blcKMl  of  cells 
representinjf  the  common  primary  stage  of  both  lymi)h(K'ytes  and 
granular  leukocytes. 

Fnlike  the  myelogenous  type,  in  the  lynii)hatic  there  is  a  liability  to 
tlic  ap{)earance  of  multiple,  minute,  subcutaneous  lymphoid  nodules. 
Inlike  the  other  form  there  is  here  characteristically  an  accompanyiii}; 
febrile  state  (102°  to  104°  F.),  with  severe  sweats,  and  development  of 
a  "typhoid  state."  The  condition  is  fatal,  and  of  shorter  course  than 
the  other  form;  and  this,  although  the  blood  picture  does  not  exhibit 
such  extreme  changes,  the  number  of  contained  white  cells  averaging 
200,(KK);  eosinophiles  and  mast  cells  are  wanting,  nor  is  there  any 
marked  increase  in  the  neutrophiles. 

Blood  Platelets. — To  the  other  constituents  af  the  bloo<l  brief  refer- 
ence may  be  made.  We  have  already  referred  to  *  'le  importance  of  the 
blood  platelets  in  the  development  of  thrombi.  These  are  small  bo.lies, 
oval  or  pear-shaped,  averaging  2n;  in  blood  smears  they  tend  to  be 
present  in  small  groups.  Even  in  normal  blood  they  show  considerable 
variation  in  their  number,  from  200,000  to  700,()(X)  per  cubic  millimeter. 
As  to  their  origin  there  has  been  much  debate,  but  since  J.  II.  iVriglit's 
studies  there  can  be  no  doubt  that  some  at  least  are  derived  from 
the  giant  cells  (megacaryocytes)  of  the  bone  marrow.  We  ou...elves 
still  hold  to  the  belief  that  in  certain  forms  of  thrombosis  a  condition 
of  plasmoschisis  results  in  the  breakins  up  of  the  red  corpuscle  into 
oval  bodies  which  are  indistinguishable  from  the  platelets  of  normal 
blood.  It  is  deserving  of  note  that  in  certain  conditions,  e.  ().,  jjcr- 
nicious  anemia,  there  is  commonly  a  marked  diminution  in  the  platelets. 
In  some  cases  of  purpura  also  they  have  been  found  wholly  absent. 
In  pneumonia  and  in  myelogenous  leukemia  they  are  increase<l  in 
number. 

Still  smaller  elements,  the  dust  bodies  or  hemoconia,  are  to  be  recog- 
nized in  the  blood.  Nicholls  and  others  regard  these  as  priMlucts  of 
disintegration,  more  particularly  of  the  erythrocytes. 

The  Lymphatic  System:  (Edema.— The  accumulation  of  serous  fluid 
transuded  from  the  vessels  in  t'  e  tissue  spaces  and  cavities  of  the  body 
constitutes  the  condition  of  f  .ema.  Distinct  names  are  given  to  such 
accumulation  of  fluid  in  particular  areas;  thus  anasarca  or  interstitial 
cedema  is  the  accumulation  in  the  tissue  spaces  of  the  limbs  and  IkmIv 
wall.  Chemosis  is  the  serous  infiltration  of  the  subconjunctival  ti>>uc. 
Ascites  is  the  accumulation  of  serous  fluid  in  the  peritoneal  cavity: 
hydrothorax,  in  the  pleural  cavity;  hydropericardium,  in  the  pericardial; 
hydrocele,  in  the  tunica  vasiinalis  testis;  internal  hydrocephalus,  in  the 
ventricles  of  the  brain;  external  hydrocephalus,  distending  the  spares 


%• 


m 


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X 


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"■«?&ii-' 


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f     I"! 


VDA'A/zl 


367 


nl  flic  pin  iirailirioiil.  \Vr  would  lay  down  tliiit  nrnmuilutions  of 
stniiiH  fluid  in  tonnininication  with  tht-  exterior,  and  t'uis  outsiile  the 
l)n.ly,arenotstrietl.\  (I'derna;  pulmonary  oBdema,  tli«r«"fi)n-,  the  nceunui- 
l.'hioii  of  fluid  in  the  air  sacs  of  the  Uuig  is,  strictly  s|H'aking,  not  a 
iiiiiiiiK'r  of  this  elass. 

<  tiir  clMssifiention  of  these  various  conditions  has  so  far  heen  faulty. 
lN<riit  sfndies  show  that  the  lymphatic  channels  ori>;inate  from  the 
Miiuiis  system  and  form  a  closwl,  freely  hranchinj;  s«ries  of  ducts 
-I  piirated  hy  aii  endothelial  liniuK  from  the  tissue  spans.  '  <  to  the 
n  Litioiiships  of  the  great  serous  cavities  of  the  Ixwly  with  '  s  system 
thiTf  is  still  dehate,  .ome  holding  (from  the  ease  and  ra»  ity  with 
wlii(  h  inilk  globules,  red  c<»rpnMles,  etc.,  pass  from  the  peritoneal 
i.nltx  into  the  lymphatic  vessels  of  the  diaphragm)  that  there  is  a 
'linrt  coinnuniication;  others,  from  histological  considerations,  deny 
the  existence  of  any  such  fn-e  communication.  For  convenience,  there- 
lore,  uc  may  regard  the  three  are-  ^  is  distinct,  and  lay  down  that 
M  n.ih  fluid  may  become  ace  umula^-  t  (1)  in  the  lymphatic  chaimels 
proper,  (2)  in  the  serous  cavities  ot  ihe  body,  and  (:j)  in  the  tissue 
M'iMrs.  Na\ ,  more,  we  can  go  farther  and  recognize  (4)  that  fluid  r' 
H I  Miiniiate  abnormally  in  the  individual  cell-.  (See  Serous  Atrophy  and 
li.\(lr..i)ie  Degeneration,  pp.  29S  and  306.) 

1  Lymphanglectasis.  — Little  need  l)e  said  regarding  the  first  of 
ilir-c  (onditioiis.  We  recognize  that,  in  consequence  of  obstruction, 
ulHtli.r congenital  or  as  the  result  of  disease  affecting  the  efferent 
l.viiipliatic  chaimels  of  certain  organs  or  area'?,  there  may  result  a  huge 
iliM.  iiMdii  of  the  lymph  channels  behind  the  point  of'obstructicm.  a 
'li>t(ii>i(.n  so  great  that  at  times  they  take  on  a  oystic  appearai  -. 
loriiiiiii;  lymph  cysts.  Such  distension  is  seen  in  congenital  conditi. 
IK  li  as  macroglossia  and  macrochellia  (p.  281).  HyKroma  oT  the  n. 
niay  he  regarded  as  of  similar  nature  (p.  281).  As  an  arqiiipea  con- 
'liiidii,  iyniphangiectasis  is  encountered  in  one  group  oi  cases  of 
<li  pliantiasis. 

-'.  Accumulation  In  the  Sorous  Cavities,  etc.— Se  -. ,  cavities  ^re  lined 
tlin.iiL;li.,iit  by  an  endothelium.  There  is  thus  normally  no  direct 
'"iiiiiniiiication  between  them  and  the  tissue  spaces  of  the  organs 
"iitain.Mi  m  those  cavities.  Thus,  an  cedematous  condition  of  the 
I'liil  Willis,  for  example,  is  not  necessarily  followed  by  ascites,  and 
'  w.  But  while  this  is  the  case,  we  must  recognize  that  there 
"iistant  circulation  of  fluid  through  these  cavities,  passing  into 
"iigh  the  endothelial  lining  and  passing  out  through  stomata 
.'-  <'f  thinning  in  particular  areas.  Thus  pigmented  matter  or 
M  introduced  into  the  peritoneal  cavity  finds  a  way  within  a  few 
-  into  the  substernal  lymph  nenles. 

I  rv(,f  inflaiiiniation  there  may  be  rapid  and  .ibundr   t  accumu- 

'  i  tiiiid  in  these  cavities.    This  inflammatory  exudate  is  more 

-!!iu,l..  serous  effiisinn;  whereas  its  salts  approximate  in  conccn- 

lo  tliose  of  the  blood  serum,  the  inflammatory  exudate  is  much 


nil'   I 


tlh  ■      Ti 

or  ,.-.  ,1 

l,:h 

Jiiil 


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fii 


th,, 

tr,!t 


.SCkS 


rilK  CAKDIOVASCVLAR  SYSTEM 


riduT  ill  proteins  than  is  noii-infiiiinniatorv  ascitic  flnicL  Very  extensive 
accinmilations  of  fluid  occur  in  tlic  various  serous  cavities  as  a  result, 
either  of  ohstniction  to  the  onward  flow  of  l)lood,  as  in  heart  disease 
and  conditions  of  jxirtal  ohstnu-tion,  or,  aj;ain,  as  a  result  of  an  inipox cr- 
ished  condition  of  tlie  blood  without  actual  obstruction  to  onflow,  hut 
with  enfeebled  circulation  and  depress>d  initrition. 

;}.  Aiiasarca.-"Rememberinj?  what  has  been  said  regarding  the  want 
of  relationship  between  the  tissue  spaces  and  the  lymph  channels 
it  will  be  seen  that  two  main  factors  determine  the  accumulation  of 
fluid  in  the  tissue  spaces:  (1)  the  rate  of  escape  of  fluid  out  of  the 
blood  vessels  into  the  tissue  spaces;  (2)  the  rate  of  escape  of  fluid  from 
the  tissue  spaces  into  the  lyni])hatic  chaiuicls.  If  fluid  can  be  carrici. 
off  by  the  lymi)halics  as  rapidly  as  it  passes  t)Ut  from  the  bhwHl,  no 
aecunudation  can  occur.  In  other  words,  an  (i-dematous  state  may  he 
brougiit  about  by  an  excessive  discharge  from  the  blood,  or,  on  the 
contrary,  by  defective  draii:.ige  away  through  the  lymj)hatic  channels. 

There  has  been  controversy  extending  over  long  years  as  to  the 
relative  importance  of  the  difi'erent  factors  found  associated  with  the 
production  of  tiie  (edcjnatous  state.  On  the  one  hand,  there  are  those 
who  would  reduce  the  problem  to  its  very  simplest  physical  factors,  who 
regard  the  lining  wall  of  the  vessels  as  nothing  more  than  a  filtration 
membrane,  who  thus  ascribe  oedema  in  the  main  to  pressure  difl'erenees. 
to  increased  discharge  from  thinned  and  dilated  c{\i)illary  and  other 
vessels.  On  the  other  hand,  an  important  body  of  investigators  holds 
that  the  endothelial  cells  lining  the  blood  vcs.sels  are  not  merely  mem- 
branes, but  possess  a  selective  capacity,  and  thus  regard  the  frdema  fluid, 
not  as  a  filtrate,  but  as  determined  by  the  state  of  mitrition  of  the  vessel 
wall.  Neither  of  these  schools  seems  to  have  paid  sufficient  attention 
to  the  problem  of  how,  once  in  the  tissue  spaces,  the  fluid  gets  into  the 
lymphatic  chaimels.  A  compromise  may  be  reached.  We  must  admit 
that  when  the  smaller  vessels  become  dilated  their  walls  become  thinned 
and  the  intercellular  spaces  of  their  endothelium  become  enlarged,  so 
that  if  there  be  any  iufTease<l  j)ressure  all  conditions  favor  an  increased 
transfusion  of  fluid  between  the  cells;  but  we  must  admit  also  tli.it 
the  endothelium  lining  the  vessels  is  by  no  means  an  inert  cell  layer. 
Thus  the  dilatation  of  ves.sels  is  not  by  any  means  necessarily  a  ]iii'-ely 
mechanical  matter;  we  must  admit  that  malnutrition  of  the  eaiiilliiry 
endothelium  and  lowered  vitality  of  the  same  is  a  factor  favoring 
oedema. 

We  may  possibly  go  farther  than  this.  Studies  upon  the  manmiiiry 
gland  in  its  stage  of  activity  indicate  that  through  the  capillary  eiulo- 
thelinm  there  is  a  selective  removal  of  fatty  matters  from  the  lilood 
for  the  use  of  the  mammary  gland  cells,  and  the  reason  for  the  (liil'cr- 
ence  between  a  serous  an*!  inflammatory  exudate,  as  again  between 
the  comp(»sition  of  cerebrospinal  fluid,  aqueous  humor  and  nM'itic 
fluid,  must  largely  be  tliis  difi'erence  in  the  selective  activities  "!  the 
vascular  endothelium  in  these  difi'erent  regions. 


.t»333E?-  <*- 


(f:DEMA 


369 


I  lie  last  few  yoars  have  seen  aiiotlicr  principle  invoked  to  explain 
<iil<iiia.     It  is  well  known  that  the  rate  and  the  direetion  of  osmosis 
<l<pi  lids  npon  the  relative  eoneentration  of  salts  on  either  side  of  the 
(.MiM^ic  niemhraiie.  and  the  ascites  and  the  anasarca  encoinitered  in 
<;iMs  of  nephritis  have  heen  ascribed  to  heaping  uj)  of  sofiium  chloride 
withiii  the  tissues  and  tissue  spaces.     Some  physicians  have  found 
iiiiirkcd  reduction  in  anasarcoiis  states  following  the  reduction  in  the 
iiiiKmiit  of  chlorides  given  as  food.    Lately,  Prof.  Fischer  has  propomided 
vet  iiMother  theory  to  explain  this  accumulation  of  fluid  in  the  tissues,  a 
th.ory  hased  upon  the  properties  of  colloidal  bodies  like  gelatin  and  pre- 
Miiiial)ly  other  proteins.     If,  for  example,  dri.  .i  gelatin  be  placed  in  plain 
wiitcr,  It  will  absorb  a  definite  (juantity  of  that  water  and  swell  up  to  a 
(.  rtMin  point.     If,  however,  the  water  be  weakly  acidified  the  amount 
Ml)M.rl.(d  becomes  very  much  greater.  If  a  freshly  removed  shecp'sorox's 
c.vc  lie  placed  in  ordinary  water,  nothing  very  much  happens;  if  it  be 
iiIm. r.i  III  weakly  acidulated  water  the  amount  of  fluid  taken  u\),  appar- 
iMtl.\  1,>  the  \  itreous,  is  so  great  that  the  eyeball  is  liable  to  undergo  rup- 
ture.    If,  again,  a  frog's  limb  be  ligatured  or  cut  oH'  and  now  be  placed 
111  the  water  in  which  previously  the  frog  had  been  swimming,  there 
iKviirs  iiii  intense  imbibition  (.f  fluid,  with  development  of  post  mortem 
•iMiisin  fi.     .\s  we  know,  when  muscle  and  other  tissues  die  the\-  become 
iiH  n  ii.iiigly  acid.     It  is  to  this  acidity  that  Prof.  Fischer  ascribes  the 
I'lilMhition  111  this  last  case,  and  he  is  inclined  therefore  to  ascribe  many 
i.i^i^  (it  (i-dema  and  anasarca  not  to  mechanical  changes  in  the  blood 
lin-iirc  or,  again,  to  changes  in  the  blood  itself,  but  to  alterations  in  the 
\<'\\"u\-a\  tissue  elements,  whereby  these  need  and  attract  to  themselves 
ji"  i-M>iiig  fluid.    The  idea  is  suggestive;  we  cannot,  however,  see  that 
It  rovrr.  tile  whole  ground;  rather  we  woiihl  say  that  we  continue  to 
rti ii-iii/(.  tJic  tollowing  types: 

/.v/"^'  </  Oulrmi.—l.  Ck)ngestive  (Edema.— This  is  the  commonest 
ton,,  ;iih1  is  met  with  in  cases  of  obstruction  to  the  venous  outflow.  Here 
ii>"l""l't.dly,  tlirrr  IS  U')  increased  capillary  pressure,  (b)  dilatation  of 
q'lllaries.  witii  tlniining  of  the  walls,  (r)   slowing  of  the  blood 
'■   iiid  iiKTcasnl  wnosity  of  the  blood,  (r/)  lowered  nutrition  and 
"t  the  .  ..piilary  wall.     Possibly  here,  secoiidarilv,  the  nutrition 
'  MMies  and  the  changes  occurring  in  those  tissues  form  a  factor 
M^atiirc  „t  the  main  vein  of  a  limb  in  a  healthv  animiJ  is  not 
'I  I'v  (edema,  though  such  (edema  will  occur  if  the  animal  be 
■    I  pii\(Tislied  state  of  health. 

CEdetna  from  Lymphatic  Obstruction.-  It  has  alreaih   Ix-en   noted 

pliiitic  obstruction,  while  leading  to  dilatation  of  the  Ivmpliatie 

I'xp  not  necessardy  cause  tedema,  in  fact  experimeiitallv  the 

;"Pliiitics  ot  a  part  may  be  ligatured  and  vet  no  cedema  mav 

.'  li''  '>l<'..d  capdlanes  are  capable  of  taking  up  fluid  from  the 

'  ^'^  they  permit  fluid  to  pass  into  them.    Hut  sometimes 

iilts,  and  here  again  the  condition  of  the  tissues  appears  to  be 

\\  <•  may  find,  for  example,  oedema  of  the  arm  occurring  in  the 


thr    . 

\itw|i 

111'   l\: 

Tim 

tnll,, 

ill    .1'! 
■> 

tli;il 

niiii 
(i(( , 
ti-i 
(i'tl( 


370 


THE  CARDIOVASCULAR  SYSTEM 


later  stiifjos  of  rancor  of  the  hreast,  when  all  the  axillary  lymphatics 
have  befome  involved;  hut  in  the  earlier  staj^e  all  those  lymjjliatics 
may  he  excised,  in  order  to  arrest  the  extension  of  the  disease,  and  no 
a'dema  shows  itself. 

In  this  eoiuiection  we  may  note  three  varieties  of  ascites,  viz., 
chylous,  chyllfonn,  and  pseudochylous  ascites.  The  first  of  these  is  due 
to  rupture  of  tlic  abdominal  lymjjhatics,  or  of  the  reeeptaculum  chyli, 
whereby  the  milky  chyle  escapes  into  the  peritoneal  cavity.  Of  similar 
orif^in  is  chylous  hydrothorax  from  rupture  of  the  thoracic  duct,  and 
chyluria,  from  rui)turc  of  the  lymphatics  of  the  pelvis  of  the  kidney  or 
of  the  bladder.  Chyliform  ascites  is  found  in  cases  of  abdominal  car- 
einoma  or  tuberculosis,  the  emulsion  of  fat  giving  the  milky  appearance, 
and  is  due  to  breaking  down  of  leukocytes  and  other  cells  that  have 
undergone  fatty  degeneration.  The  percentage  of  fat  in  these  cases  may 
be  much  higher  than  in  the  former.  In  pseudochylous  ascites  the  milky 
appearance  is  associated  with  absence  of  fat,  and  is  brought  about 
either  by  mucoid  substances  or  suspended  proteins. 

'.i.  Inflammatory  (Edema.— All  acute  inflammation  is  accompanied  by 
a  local  increased  i)assage  of  fluid  out  of  the  vessels.  The  fluid  in  these 
cases  approaches  more  nearly  in  its  composition  to  the  blood  plasma  than 
does  that  of  congestive  a-dema.  As  will  be  remembered,  the  capillary 
endothelium  shows  a  striking  series  of  changes  in  acute  inflammitinn, 
and  to  this  changed  condition  we  must  largely  ascribe  the  increased 
exudate,  although  here  also  we  must  recognize  that  the  tissue  cells 
in  the  involved  area  exhibit  marked  disintegrative  changes  which  may 
undoubtedly  attract  more  fluid. 

4.  Toxic  CEdema. — We  know,  experimentally,  that  there  are  sub- 
stances which  act  as  lymphag<igues,  inducing  increased  lymph  formation. 
In  the  ease  or  some  of  these  no  noticeable  change  is  exerted  on  the  circu- 
lation. The  difference  in  the  distribution  of  the  anasarca  in  heart  and 
kidney  disease,  respectively,  would  suggest  that  the  toxic  substiinces 
circulating  in  the  blood  have  i)ossibly  a  different  effect  on  the  capillary 
wall  in  the  diverse  conditions. 

").  Neuropathic  (Edema.— We  have  already  emphasized  on  more  than 
one  occasion,  that  the  central  nervous  sy.stem  of  itself  can  set  uj)  dis- 
turbances of  the  same  character  as  those  due  to  the  action  of  local 
nojca;.  The  same  is  true  in  connection  with  this  matter  of  (vdcnm. 
This  is  well  seen  in  herpes  zoster,  where  irritation  of  one  jxjstcrior 
spinal  ganglion  is  followcfl  by  cedema  accurately  mapping  out  the  super- 
ficial area  su])plied  by  that  ])articular  spinal  nerve.  Tliere  also  occur 
certain  remarkable  angioneurotic  oedemas,  characterized  by  the  sudden 
pouring  out  of  fluid  into  i)articular  areas  of  the  internal  organs  or  skin, 
without  any  recognizable  cause.  It  is  true  that  these  resemble  iinich 
the  urticaria  and  localized  (rdcina  seen  in  cases  of  idiosyncrasy  iimi  tood- 
poisoning,  conditions  which  we  have  noted  (p.  117)  are  in  turn  iiiiied 
to  anaphylactic  phenomena.     It  may  eventually  be  determined  that 


THE  HEART:  GENERAL  CONSIDERATIONS 


371 


ill  tlicse  we  deal  with  something  more  than  simple  uncomplicated 
\iiMiniotor  disturbances. 

i;.  Hydrops  ex  Vacuo.  Finally,  accompanying  the  atrophy  of  tissues 
.ncldscd  withm  spaces  having  relatively  resistant  walls,  there  may  he 
,1  "replacement  dropsy."  The  most  familiar  example  of  this  is  noted  in 
-tiiilc  and  other  atro])hies  of  the  brain  where  there  niav  be  marked 
iH  ruinnlation  of  flui<l,  either  externally  in  the  pia  arachnoid  spaces,  or 
internally  in  the  ventricles,  or  both.  Hemorrhagic  and  necrotic  cysts 
p.  I'lto)  belong  to  the  same  category. 


1 
I 


THE  HEART,  BLOOD  VESSELS,  AND  LYMPHATIC  VESSELS 


THE  HEART:  GENERAL  CONSmERATIONS 

'I'Ik'  striking  progress  made  during  the  last  few  vears  in  the  com- 
Iir.  Ii.iision  and  treatment  of  heart  diseas(>  have  been  preeminently 
;iilv;iii(e(l  by  the  study  of  normal  and  perverted  function.  For  such 
a  -tii.ly,  It  is  true,  a  knowledge  of  the  anatomy  and  histologv,  and, 
iiiilcnl,  .)f  the  embryology  of  the  organ  has  been  a  prerecpasi'te,  but 
iiii'i":il.te<l!y  at  the  present  time  a  knowledge  of  the  pathological 
J)  i>M(.l();;y  of  the  heart  is  of  profound  importance  to  the  medical  man. 
liiu>  ut  necessity  a  chapter  must  be  devoted  to  cardiac  function  ami 
It-  iii-tiirl)ances. 

I'unrti.mally  the  heart  is  nothing  more  nor  less  than  a  pump— a 
'l"ii  ,1c  pump  and  double-actioned-the  indications  being  that  the  filling 
"t  the  \ciitncles  IS  not  a  passive  process,  but  in  part  at  least  active, 
'liif  tn  suction  exerted  by  the  expanding  ventricles;  it  is  a  suction 
Piiiiip.  cN  ,11  if,  to  a  greater  extent,  it  is  a  propulsive  organ.  With  this 
It  I-  ixtraonhnarily  responsive  to  variations  in  the  work  it  is  called 
iip'"i  ">  accomplish,  altering  its  rate  or  rhythm  and  the  force  of  indi- 
y'ln.il  iMats^according  to  the  amount  of  blood  supplied,  the  resistance 

ii- 
t;H  I 

I 

III, 
iiit! 
ililF. 


Iii;i.    ; 

1.  ■ 

th.-v 
Illnl  ,! 


t  winch  the  blood  is  propelled,  and  the  stimuli  received  from  the 
I-  rriitres.    We  must,  even  if  rapidly,  mention  in  order  the  varying 

\\  nch  modify  its  activity,  taking  for  granted  a  km)wledge  of  the 

'itiiiiis  of  its  anatomy  and  cmbryogeny. 

•I  iMjitter  of  difficulty  to  determine  tfie  order  in  which  to  treat 
'iMiis  sections  of  our  subject,  and  this  because  there  is  such  an 

'    interaction  between  the  work  and  the  disturbances  of  the 

'  pnrtions  of  tile  heart,  that  it  is  impossible  to  discuss  one  phase 
■   H'lun  without  referring  to  the  other.    The  following,  however 

■ id  helpful: 

'     Auricles.    -We  must  regard  the  auricles  as  distensible  pouches 

'  i\  clx  weak  muscular  walls.    Their  very  structure  indicates  that 

riMTvoirs  to  accumulate  blood  during  ventricular  systole 

r  It  freely  into  the  ventricles  during  their  diastole.    It  is  true 


372 


THE  CARDIOVASCULAR  SYSTEM 


m 


li 


that  these  walls  are  muscular,  true  further,  as  has  been  abundantiv 
demonstrated  .hiring  the  last  few  years,  that  the  heart  beat  commences 
at  tlie  sino-auricular  rin>;,  where  the  veiue  cavie  open  into    he  auricle, 
and  from  there  the  contraction  spreads  through  the  auricle,  and  so 
later  to  the  ventricle^;  but  in  the  auricles  the  contraction  is  relatively 
feeble.     I'nder  normal  conditions  there  is  indeed  verv  little  need  for 
vigorous  contract'  )n.     The  very  size  of  the  auriculoventricular  orifice, 
as  we  shall   jwint  out.  and   the  active  dilatation  of  the  ventricles 
together  afford  an  easy  How  of  blood  into  the  ventricular  chambers— 
a  flow  so  easy  that  no  proper  valves  are  present  at  the  orifices  of  the 
vensE  cayje  and  the  pulmonary  veins  respecti\cly.    At  most,  with  the 
contraction  of  the  circular  musculature  around  each  orifice,  there  is  a 
dimiiuition  in  their  lumen.    It  thus  becomes  a  matter  still  under  debate 
as  to  whether  witii  each  auricular  systole  some  small  amount  of  blood 
IS  not  driven  backward  into  the  veins.     As  already  noted,  the  flow 
forward  into  the  ventricles  is  so  easy  that  if  normally  such  legurgi- 
tation  is  present,  it  is  not  propagated,  and  does  not,  for  example,  show 
Itself  in  the  neck  veins. 

2.  Venous  Pulse.— If,  however,  there  be  obstruction  to  the  onflow  of 
blood  and  dilatation  of  the  auricle,  such  regurgitation  easily  manifests 
Itself.  There  have  been  luinierous  conflicting  studies  upon  "this  matter 
durmg  the  last  century.  We  owe,  more  especially,  to  Dr.  -James 
i.Iackenzie  and  his  em^)l()yment  o'  Jie  i)<)lygraph  (/.  e.]  of  an  instrument 
pernntting  simultaneous  records  of  venous  pulse,  apex  beat,  arterial 
pulse,  etc.)  that  today  we  recognize  the  different  forms  of  venous  pulse 
and  are  able  to  translate  the  significance  of  the  same.  Mackenzie  has 
shown  very  clearly  tliat  according  to  their  position  relative  to  the  phases 
of  the  carotid  pulse,  we  may  recognize  three  separate  waves  in  the 
venous  pulse  (r.  (/.,  in  that  seen  in  the  jugular  vein). 

I.  If  the  auricle  l)e  distended  and  its  contraction  be  powerful,  there 
may  be  pro|)agated  along  the  vein  a  wave  corresponding  with  the 
auricular  systole. 

II.  If  the  auriculoventricular  valve  be  incompetent  there  mny  be 
propagaied  backward  a  regurgitant  wave  corresponding  in  time  with 
the  ventricular  systole,  and 

III.  Owing  to  the  .-hjse  proximity  of  the  carotid  and  jugular  witiiin 
the  same  shcatli,  an  active  impulse  propagated  along  the  carotid  iirtery 
may  be  transmitted  to  the  column  of  blood  in  the  vein  showing  itself 
a  little  later  than  the  regurgitant  ventricular  wave. 

Sometimes  all  three  of  these  waves  are  present  together.  Where 
there  is  little  or  no  regur;itation  through  the  tricuspid,  the  aiirii  iilar 
systolic  wave  alone  may  be  present,  as  in  the  rare  condition  of  tri<  uspid 
stenosis.  Where  the  tricuspid  is  markedly  incompetent,  and  thnmgh 
regurgitation  the  right  auricle  is  overdistended  and  enfeeble<l  s.-  that 
its  systole  is  much  weakened,  then  the  ventricular  systolic  wa\<'  may 
l)e  of  great  size,  the  other  two  scarce  recognizable. 

In  other  words,  a  careful  study  of  the  venous  pulse  is  aft'o- 


::  us 


•WWT 


THE  HEART:  CKSKRAL  COXSIDERATIONS 


373 


valuable  evult-iice  regarding  the  state  of  the  right  heart,  as  compared 
with  hat  of  the  left.  The  indications  are  that  regurgitation  of  blood 
int..  the  Y'lns  ,s  relatnely  common,  that,  as  King  showed  long  ago,  it 
acts  as  a  factor  ()f  saf'-ty,  i)rcventing  excessive  strain  upot.  the  delicate 
aiin.ies.  as  again  upon  the  weak  right  ventricle.  We  shall  have  more 
to  >ay  regarding  regurgitation  and  auricular  function  in  connection 
with  our  next  section. 

::   The    Auriculoventricular   Valves.     As   already    noted,    the   most 
striking  feature  of  these  valves  is  their  relativelv  large  size,  so  that  their 
<.rit..rs  permit  an  easy  filling  of  the  ventricles  in  diastole,  and  this 
w  thuiit  resistance.     The  very  size  of  the  orifices  demands  a  special 
nurhamsm.  so  that  during  systole  the  pressure  on  the  under  surfaces 
ot  tlic  large  valve  flaps  does  not  make  them  give  wav  and  allow  escape 
int..  the  auricular  chaml)er.    This  mechanism  is  afforded  bv  the  i)apil- 
lary  muscles  and  the  chorda"  tendineie.    The  chord*  are  attached  in 
r..«.  to  the  under  aspect  of  each  valve,  and  originate  from  the  papillarv 
niiixl.s  n,  such  a  w-ay  that  each  muscle  gives  origin  to  chords  passing 
to  .a.l.  valve  flap.    1  hey  are  further  so  attached,  some  to  the  verv  edge 
ot  th,.  va  ve,  others  to  the  under  surface,  that  when  the  valve  flaps  are 
I'jill'H.ii.'d  up  by  the  pressure  of  blood  in  the  ventricle,  the  flaps  are  not 
al.s.,hit(ly  flat,  but  have  a  marked  convexity  upward  in  such  a  wav 
tliat  the  distal  or  terminal  border  of  the  main  flaps  does  not  meet  th"e 
Hi;.'  ot  Its  fellow,  but  there  is  apposition  of  the  auricular  aspects  of 
the  t.Timnal  portions  of  these  valves,  and  i;.  this  wav  the  greater  the 
pnsMirc  withm  the  ventricle  the  more  firm  is  the  closiirc  of  the  valve 
As  to  the  action  of  the  papillary  muscles,  there  is  this  to  be  noted 
that  II,  systole  it  is  the  breadth  and  not  the  length  of  the  \entricles 
that   iiiui.Tgoes    serious    alteration.     Were  the  papillarv  muscus  to 
<"iitni.  t  simultaneously  with  the  ventricular  wall  while  the  ventricle  is 

^" :"".<lt'<l.  the  tendency  would  be  to  keep  the  valve  open  and  favor 

r.i:iirmtation.  Hoy  and  Adami  have  shown  that  the  papillarv  nusdes 
an>  til.  last  portion  of  the  ventricular  wall  to  und-rgo  eontract:r)n  It 
woiiM  thus  seem  that  these  muscles  come  into  action  after  the  increasing 
pr.;"ur,  within  the  ventricle  in  systole  has  led  alreadv  to  the  appo- 
ptjoi,  ..I  iIh.  Haps,  and  that  by  their  contraction  thev  pn-vent  excessive 

: '"'-"'  t'«'  valve  into  the  auricular  chamber.    Thev  and  other 

"!'->  ,  r.  have  shown  that  the  papillary  contraction  mavbe  irregular 
"r  "II  I..-  wanting,  and  have  associated  these  irregularities  with  other 
|li  nirl.u,,,.  ,„  the  heart  action.  The  main  cause,  however,  of  regurgi- 
tnti.  I  ,  is  .listension  from  an  overfilling  of  the  ventricle.  This  we  shall 
•Jixii-  111  iiur  next  section. 
The  Ventricles.  These  are  essentially  the  pumping  apparatus  of 
'  '  ■  '■t.  and  their  structure  in  tliis  relationship  shows  certain  inter- 
■itiires.  Each  ventricle  does  not  contract  as  a  sphere  and 
"lie  narrowed  in  every  direction.  The  lavers  of  muscle  are 
;-v.l  tliat  with  contraction  the  length  is  practicallv  unaltered, 
'1  systole  singularly  little  internal  pressure  is  exerted  upon  the 


th. 

•■still: 

thii- 
s"  an 

••■O  tllll 


374 


THE  CARDIOVASCULAR  SYSTEM 


h    < 

IK'    i 

IS'-  I 


apex,  whicli,  iiulecd,  is  sinpularly  thin.    Tli-  arrangement  i»f  the  fibres 
and  their  mode  of  contraction  are  such  that  the  walls  of  the  apical 
portion  of  cither  ventricle,  and  particularly  of  the  stronger  left  ventricle, 
are  brought  together  and  compressed.    Above  the  apices  of  the  papillary 
muscles  there  is  left  a  small  chamber  around  each  auricuh)ventricu]ar 
valve,  which  even  in  the  completcst  contraction  is  never  entirely 
emptied.    The  more  recent  studies  of  the  electric  reactions  of  the  heart 
show  that  the  contraction  begins  at  the  base  and  travels  down  toward 
the  apex,  and,  as  already  noted,  it  affects  the  i)apillrrv  muscles  at  a 
comparatively  late  period.    But,  also,  with  Krehl,  we  are  led  to  recog- 
nize a  third  section  of  the  muscle    the  ring  nuisculature,  controlling 
the  )rifice  of  the  ventricles.     This  i>  held  to  play  an  important  part  in 
preventmg  regurgitation.     Where  its  tonus  is  reduced  and  becomes 
enfeebled  the  eidargenient  of  the  auriculoventrieular  orifice  leads  to 
incompetence.    In  the  right  heart  also  we  have  to  distinguish  a  coiuis 
or  jKissage  leading  uj)  to  the  pulmonary  artery.    Embrvologicallv  this 
originates  as  a  separate  jiorlion  of  the  \  entricular  cavity!    Lasth.'it  has 
to  be  recalled  that  the  weaker  right  ventricle  is  ai)plic«"l  in  a  soiiuwliat 
cresceiitic  manner  upon  the  side  of  the  more  conical  left  ventricle,  atid 
that  the  musculature  of  the  two  ventricles  is  not  absolutelv  distinct. 
A  considerabie  number  of  the  more  superficial  fibres  pass  from  the  one 
ventricle   to  the   other.     Some  clinical   obser\ers   have  reconled  an 
independent  rate  of  contraction  of  the  two  hearts.    From  anatomical 
considerations  it  is  difficult  to  see  how  this  can  occur. 

While  the  cardiac  muscle  presents  certain  distinctive  features  in  its 
mode  of  contraction,  we  must  regard  it  in  most  respects  as  possessing 
the  same  general  properties  as  other  striated  muscle.    If  we  attach  a 
weight  to  a  resting  band  of  muscle,  such  as  that  of  the  frog's  leg,  we 
find  that  the  b-ind  undergoes  progressive  elongation.     So,  similarly, 
if  under  pressure  increasing  volumes  of  blood  enter  the  ventricles,  tlie 
ventricle  expands  antl  undergoes  distension.     It  is  very  probable  that, 
as  with  skeletal  muscle,  there  is  a  certain  optimum  load  under  which 
the  maximum  amount  of  work  is  accomplished,  and  that  thus  a  moder- 
ate grade  of  distension  of  the  vf  utricles  is  most  favorable  for  the  iicart 
work.    Without  entering  into  the  physics  of  the  matter  we  would  lure 
point  out  that  with  increased  exercise  up  to  a  certain  point  the  ventricles 
of  the  heart  undergo  a  physiological  distension,  which  seems  to  i)i-  to 
their  advantage,  inasmuch  as  in  thi;  state  a  smaller  range  of  contrac- 
tion of  the  individual  muscle  fibres  drives  out  a  relatively  much  larger 
amount  of  blood  into  the  arteries.    Saying  this,  it  must  be  remeinlMTcd 
that  the  normal  heart  possesses  a  very  large  reserve  of  force.     It  is 
found,  for  example,  that  with  the  internal  pressure  raised  to  four  times 
the  normal,  the  organ  still  continues  to  pump  out  regularly  into  the 
aorta.    Thus  it  can  stand  temporary  increase  of  work  with  comparative 
ease.    Nevertheless,  this  reserve  of  force  can  be  used  up  either  by  nial- 
nutritio!!  or  by  continued  work  up  to  the  limit  of  the  capacity  of  the 
organ.    Where  this  is  the  case  we  find  that  the  organ  undergoes  what 


THE  HEART:  GENERAL  CONSIDERATIONS 


375 


iiuw  we  may  term  "pathological  dilatation."  Even  in  this  dilatation, 
jiwItriiiK  from  the  continued  stre:ij;th  of  the  pulse  and  the  arterial 
Mi.(m1  pressure,  the  organ  may  continue  to  function  adequately,  and 
i!ri\<'  forward  the  amount  of  blood  necessary  for  the  organism  at  large, 
liiit  this  only  so  long  as  the  individual  is  at  rest.  J{elatively  slight 
(Mrtion,  or  increased  demand  upon  .ne  organ  brings  about 'cardiac 
l.iiliire  and  acute  distress,  or  otherwise  we  recognize  three  grades— 
lihysiological  distension,  pathological  dilatation  with  partial  incom- 
pctciici',  and  cardiac  failure. 

It  ;<^  l)robable  that  in  all  cases  of  what  we  have  termed  "pathological 
ililiitution"  there  is  incompetence  to  the  extent  that  regurgitation  shows 
itH'lt.  .\s  already  pointed  out,  such  regurgitation  through  the  dilated 
:iiiri(iil()ventricular  orifices  is  of  the  nature  of  a  safety  valve  action, 
\vlK'r(l)y  the  strain  is  removed  from  the  ventricular  muscle  at  the 
IMwsil.ly  lesser  expense  of  congestion  of  the  lungs  and  abdominal  and 
(itlitr  organs. 

S.)  long  as  the  heart  is  working  within  the  limits  of  its  reserve  force 
we  fni.I,  m  accordance  with  the  principle  laid  down  on  i)age  142,  that 
imnasfd  w.)rk  leads  to  hypertrophy.  When,  therefore,  we  encounter 
tiu'  <'on(iition  of  marked  increase  in  the  volume  of  the  ventricular 
MINX  Ic,  we  must  not  regard  this  in  itself  as  a  pathological  condition.  It 
b  iiilaptive,  but,  at  the  same  time,  is  an  indication  of  the  existence 
"t  x.ine  condition,  either  in  the  heart  itself,  as  from  «lisease  of  the 
\iil\.js  and  obstruction  to  the  onflow  of  the  bloo<l,  or  outside  the  heart, 
«  Ik  tlur  ni  the  form  of  obstructive  disease  of  the  lungs  or  of  rljstruction 
to  t  i(.  onflow  through  the  systemic  arte.ies.  It  is  an  indication  that 
«<  liavc  to  seek  for  the  cau.=e  of  the  increased  work  upon  the  heart, 
titlK  r  witlnn  the  organ  itself  or  outside  it. 

Systole  and  Diastole.— That  systole,  the  contraction  of  the  cardiac 
•iiiiM  I,.,  IS  an  active  process  is  obvious.  It  is  less  generallv  recognised 
that  ,  lastole  IS  likewise  active.  While  this  has  been  suggested  by 
X  \. ml  observers,  and  while  the  very  firmness  and  resistance  offered  to 
IT,- lire  when  the  beating  heart  is  taken  between  finger  and  thumb  is 
|ii  It  ,11  opposed  +o  the  view  that  the  diastolic  filling  of  the  ventricles 
',..''  l''"-''^*^'  I)r<>cess,  it  is  only  comi)aratively  recentlv  that  Stefani  has 
■III""  •'!  absolute  demonstration  of  the  active  elongation  of  the  heart 
|||||  H,  Ho  has  demonstrated  that  blood  enters  the  ventricles,  and 
1^  K  .|"  llcl  into  the  auricles  when  the  pericardial  pressure  (the  pressure 
"M  tile  heart  walls)  is  2')  cm.  of  water  higher  than  that  in  the 
iiva-.  Only  by  the  suction  action  of  the  ventricles,  bv  their 
'il'itation,  can  there  be  continuance  of  the  circulation  under 
"iKiitions. 

'  iibservations  throw  light  upon  the  hypertrophy  of  the  Ief+  ven- 

•A  infrequently  present  in  cases  of  mitral  stenosis;  thev  suggest 

-  \<ntricle  undergoes  increased  work  in  diastolic  suction  of  blood 

the  narrow  orifice.     It  appears  that  under  usual  conditions, 

ire  IS  no  resistance  to  inflow,  the  free  entry  of  blood  into  the 


Vll! 

Ilrii 

th, 

T 
tri.l 
tli.if 
li.;- 
«li, 


liTi] 


THE  CARDIOVASCCLAR  SYSTEM 


von  ru-lcs  prrvoiits  ai.\-  prononiiCMl  i.c«ativt'  prossun-  in  these  .-avities 
so  tl.at  intravH.truular  pressure  curves  ..ftei.  sl.nw  little  ..r  n..  i..,li(,,- 
...n  of  tins  phase  of  active  exjmnsiun.  By  analogy  w  „n,st  suj.pos,. 
that  the  muscnlar  walls  ot  the  arteries  possess  likewise  these  two 
properties,  an.i  that  .lilatati..n  um.I.t  the  a<ti..M  of  Nusodilators  is  as 
mudi  an  active  pro<-ess  as  is  constriction  nn.ier  the  vasoconstrictors 

The  Semilunar  Valves.  -These  guaniing  each  a  smaller  orifice  ,1,, 
not  nec.l  tlie  accessory  structures  present  in  the  auriculovcntricular 
valves.  J  he  cusps  clos(>  securely,  owing  to  the  relativelv  large  extent 
of  the  peripheral  i...rtioi,s  of  .-ach  of  them  which  comes  into  a,,position 
with  Its  neighbor,  an<l  m  this  relationship  it  is  interesting  to  note  that 
acute  .hseasc  .Iocs  not  attect  the  cusps  along  their  e.lges,  hut  imme<liat,-lv 
below  the  zone  of  aj)position,  where  appears  to  be  the  region  of  greatest 
strain.  ^  vin.^i. 

From  tiie  point  of  view  of  the  work  of  the  heart,  the  relationship  uf 
the  aortic  val\e  to  the  coronaries  is  of  considerable  importance.  The 
older  view  that  when  open  the  cusi.s  occlude  the  coronarv  orifices,  is  n..w 
known  to  be  wrong.  There  is  a  free <.iitrance  of  blood  in'to  these  vess.Is 
both  during  systole  and  during  diastole.  Thanks  to  the  existence  of  the 
sinuses  of  \alsalva.  there  is  at  all  ,,erio.ls  a  space  between  the  upper 
aspect  ot  the  cusps  ami  the  aortic  wall. 

The  Coronary  Circulation.-As  above  stated,  blood  enters  the  coro- 
naries during  systole.  There  is.  however,  no  doubt  that  with  the 
contraction  ot  the  ventricular  muscle,  the  intramuscular  branches  of 
the  conjnaries  nnderg..  compression,  and  the  heart  muscle  is  com- 
paratively bloodless,  (•ompare.l.  that  is,  with  its  condition  .luring 
diastole.  It  IS  ,  unng  this  hitter  and  longer  period  that  the  main 
nourishment  of  the  heart  fibres  occurs. 

A  study  of  sections  where  there  has  been  extensive  destruction  of 
the  ventricular  muscle,  through  malnutrition,  shows  that  there  i.  a 
zone  or  layer  of  this  niusde  under  the  emlocardium  which  still  survives. 
(  Icarly,  therefore,  there  is  in  the  mammal,  as  is  the  case  to  a  much 
greater  extent  m  co  .l-l,loo.le<l  animals,  a  certain  amount  of  nourish- 
ment ot  the  myocardium  from  the  ventricular  chambers 

1  o  the  relationship  of  the  diHVrcnt  branches  of  the  coronarv  arteries 
to  each  other  we  have  already  referred  in  discussing  the  subject  of 
infarcts  (p.  .542).    We  wouhl  only  recall  that  anastomoses  occur,  hut 
they  are  small  and  infrequent.    As  shown  by  Kronecker,  ligatnn'  of 
certain  of  the  mam  braiiciics.  particularly  of  the  left  side,  nun   he 
followe.1  in  a  tew  minutes  by  fil)rillati..n  of  the  whole  heart,  with  resiilt- 
juit  death.     1  his  does  not.  it  is  true,  occur  alwa\  s,  but  pc.ssiblv  throws 
iiglit  upon  su.lden  death  in  some  cases  of  angina  pectoris,  a  condition 
wlucli  is  especialiy  associated  with  obstructive  <lisease  of  the  coronarv 
arteries.    l<or  the  supervention  of  an  attack  of  angina,  it  does  not  <vvm 
necessary  that  there  be  complete  obliterative  spasm  or  other  fori:,  of 
closure  ot  the  left  coronary  or  its  branches.     There  must,  huv-.ar, 
be  some  narrowing  or  rigidity  of  these  arteries  bv  disease,  so  that  a 


TtlE  HEART:  GESKRM.  (OS,->l DKRATIOSS  .{77 

..II  tW  inm-Hsnl  work  .-annot  he  met   hy  ,lilatuti„n  arnl  incmis,.,! 
nutrmo,,  „f     IH.   Iu.art   ,m„s<U..     TI.,-  syn.pto.ns.   that    is,  of  «,.«,•  a 
,"..uns.an- tl.osoo.  a  n-lativ,-  an..,nia  of  th.  vn.trin.lar  n  us..!.,   'r 
M.iiii'  area  of  tin-  saiiu'.  ' 

The  Nervous  Meclumism     It  is  i„  tl.is  co.nuHtion  that  .luring 
The   fatnnsic    Apparatus.     I     If   tlu-   .afs   h.-art,    for   ..xa...i,lo,    bo 

I.  f  l.n„ato,l    ,loo,i  u.Klor  proper  c-o„.litio„s.  th.-  or^^an  will  1,,.^!,,  to 

i"  .'t  an.l  ..ontnuu.  to  contrac-t  activdy  an.l  with  n-«„laritx   for  an  honr 
or  mor...    It  ,s  d.ar.  thon-fore.  that  thm-  is  a  ,n..,.haniMn  l,v  win  • 
.  r,..„loyentru-nl-  -  c.ontra,t.ons  pnHr...|  rognlarly  an.l  porio.liVallv  in 
till'  al.sciice  .)t  (rntral  stinnilation. 

,.-    ''''*■'■',  "'^.i'  .•^n>aratc.l   strips  .)f  mammalian   \-..ntricnlar  nuiscle 

Inrt.T).  ,1  .l..hl.nnato.l  l.l„...|  |„.  perfns...!  through  th.  attadu'l  \ZX 
o  tin.  ...ronary  artery  sp.,ntaneons  .-..ntra.-tions  .,r  heats  will,  nn.ler 
t..  o  ah  e  <"n.ht>..ns.  show  themselves.     It  is  c-lear.  theref.,re,  that  the 

o    n.,,„.ns  o»  „,.|,v,.lnal  fihres  may  oeenr  in  tlu-  al.sen.r  ..f  anv  stimni 
trnin  o,alize.l  pinKli.,.ne  .-entres.  situate.!  in  the  heart 

...It  ,s  st.ll  a  n.atter  ..f  .lehate  as  to  whether  this  last  ..r.ler  of  eon- 
tr.,rt,n,us  „|,.,museular,  an.l  this  lurause  it  seems  i.npossihie  to  isolate 
anv  part  ..t  the  heart  mus..ulature  whi.-h  .l..es  not  show'  fine  nerve  fiS. 
a-o(iate.l  with  whu h  are  scattered  ner\e  eelN 

1    riH.se  wh..h..l.l  t..  the  i.li..museular  hypothesis  p.,int  out  that 

"  t .,..  ...Kk  an.l  ..ther  embry.,s  the  heart  is  .lev..|ope.l  an.l  aetivelv 

U-.Ujj„r  .„n,r  dm,,  brjore  uu„  uenr  fibre,  ami  <rlh  rmch  it  from  the 

|v.  Y  ......  .,,.,,r,.    Then,  is  no  questi..n.  therefore,  that  J :Z^ 

m<     ' .  r    tissue  possesses  the  power  of  sp.,ntaneous  c.ntraeti.Mi.     But 

;•.".■...  as  pou,te.l  out  by  Gaskell,  this  embry..ni.-  tissue  is 

qUnl  1,^   the  heart  musele  |.r..per.    The  striking  p.,int  is  that  a 

;  n;;n  ..  tins  prnn.nve  c-anliae  „„,sde  renu.ins  an.l  '  .Ltitutes       er 

'I".""  ;  "  itiates  an.l  regulates  the  contractions  of  the  ..rgan  as  a  whole 
•'      ■""l>"->on  Sj,str,».-Our  knowlclge  of  this  sNstem  is  base.1  upon 
tlHoi)M  nations  of  (Jaskdl  (l,S,s;{),  Kent  (l,S<)->)  Hi;   Ir    l^c-     To 

;-  nsbynK)rerece„tw.,rkers.   Atthejnnctionof thesuperiorvena 

'■'  ■'  -   '    lu-  ngh    auru  e  is  an  accnmulati..n  of  peculiar  small  muscle 


Illrlit 

SIIJIC' 

X'Culii 

of  t!  . 
then 
'llir  ■ 

lllll:  ■ 


,    .  •   .  - —  — •  •"^-......,,i,„ii  (,i  pecunar  small  muscle 

..   e  nbed(le.l  in  a  densely  packe.l  .-onnective  ti.ssue.    Strands 

r  ,rlls  pass  from  this  s.,-calle.l  sino-auricular  node  ..ver  the  inner 

^      the  auricular   .all  and  appear  t.,  be  .lirectly  connecte.1  with  a 

r  ;,';!'' *'"'"wf°*?''^"  °^*'  ^'*""**'''  i"  the  neighb..rhoo.l 
■■n.n.  rx  sinus  at  the  ba.se  .,f  the  auricular  septum.    From  this 

frl     ^    )  ^'"^heathed  ,n  a  fibn.us  canal,  which  at  the  y>«r* 
"""  •■'epU  of  the  ventnde  divides,  the  one  branch  becoming 


378 


THE  CAHDKn  WSCVLAR  SYSTEM 


.•..Mtrihuh;,!  t.)  tl...  U-ft,  tl...  otluT  t.,  tlu.  ri^l.t  vH.tri.l...  Ka,I,  hn.n.l, 
K  v.s  oil  tn-.,n..nt  .|>v,>,o,.-,  ru,.,m,«  „„,|,.r  ,|u.  rn.l....anlin.n.  tl,.-  ,„...i 
ar  ...n..af n„s  U„,^  .■..ntnlM.t,.!  t.,  tl...  papillary  ,nuM.|..s  ..f  ..i,|,..r  vn" 
tr„l...  a.ul  InrtluT  lK.,.,„„,nj;  ,iir..,.t|y  <„,.ti.um„s  wi,|,  tlu-  s.,lH.M.I..,.a  . 
;  "I  "<'tw..rk  ..I  Purkinj.  ceUs,  whi.l,  li,...  th.-  int.Tior  ,.r  l..,tl.  vontri.i: . 
I  luM.  c-lls  hav,.  l„...„  known  lor  lon«,  an.l  l.a.l  Intlu-rto  l.mi  r.-Kanlr.j 
as  nn.naturo  ..r  on.l.rvo.n..  nu.s..|,.  fil,r..s.  It  is  tl.ro„«h  tlu-s.  that  J 
network  ..onus  n.to  .l,r.-.t  .■...nnnnueation  with  the  ventrieular  nn.s,'!!. 

<1.   It  shonl.l  Ik,  a.l.l..,l  that  associate.!  with  this  system  is  an  al.nn.lant 
plexus  .,f  f,„e  nerve  fil.ri  s  with  .nrasional  Kan.^li.in  ,rlls.  an.l  t  I .! 

snu,-anrKular  no. le  rea-ives  hran.-lu..  l,.,th  Cr.wn  the  Jagus  a 
syinpatlu'tic  (aeeelerat.)rj  nerves. 

The  Kr..at  imp..rtanee  of  this  system  lies  in  this,  that  pra.ti.'allv  all 
reec.nt  w.,rk  .lenu.nstrates  that  tlu-  r..,M,lar  e..ntraetions  of  th  ..r 
are  mtnnate  y  as.s.„-,at..l  with  its  pres....,.-  an.l  lnn,ti.,nal  inte^ritv 
Ihe  r.-,,;nt  stn.hc-s  w,th  the  el..,tr.Kanlio«raph  show  that  the  wave  of 
.■..ntra.t.on  Ik-k.,,s  at  the  sino-anri.nlar  n...l,..  ,1)  |}.,„<,ve  the  n.nle 
a",  the  .•ontra.tions  .ras...  ,2)  iVstr-.y  th,-  a.,ri<M.lovn,tri.nlar  no,le 
an.l  (•oor.hnat...n  lu-tw.-n  anrules  an.l  ventricles  ...mes  t..  an  eml  The 
anruhs  .ontUMie  LeatniK  at  th,-  r.-Kular  rate;  the  ventri.-les  at  first 
.|nu.se..nt  slowly  assunu;  a  rhythm  .,f  tlu-ir  .,wn  (the  i.liov.-ntri.Milar 
rhythm)  tlu-  rate  .,t  whi.h  .s  ron«hly  one-half  t..  .,ne-thir.l  .,f  that  ..f 
tile  auricles. 

Our  pr..s,.nt  c.,nc.-ption  .,f  norma!  canliac  actinty  is  that  recurrent 
pen.Khc  stnnul.  pnuee.!  from  the  sino-auricular  no.le  which  had  first 
t..  a  contractu.n  of  the  anrules.  an.!  f.,llowing  upon  this,  as  the  wave 
exten.ls  .l.)wn  the  auricu!.)vcntricu!ar  Ijun.!!.-,  the  ventricles  in  th.ir 
urn  un.lerK.,  c..:.vra..t.on.    An.l  we  regar.!  ♦   .  rat,-,  an.l,  to  .some  .xt.nt. 
the    .,rce  ot  the  successive  waves  as  influcce.!  I,y  afferent  va^ns  ,,,,.1 
accelerat..r  m   lu-iu-es  reachniK  tlie  sin.,-auricular  no.le.     We  re,.,,.,!.,- 
hirther,  that  these  mo,lihcati,.ns  in  the  heart  work  are  set  up  l.v  i^fln- 
ences  a,tn  ,  upon  the  va^us  an,!  a,-crierat,>r  centres  of  the  bulb.  wh,tlui 
.lirect  through  the  ,nflu.-n,r  of  .ir.-ulatiuK  Mo,.,!  upon  tho.se  centr.>,  or 
rell.-N.  ,■,  her  from  stimuli  reacliiuK  thos,-  ..ontrt-s  fron:  other  orjjans  ..r 
parts  ol  the  bo.ly,  .,r  fr.m,  the  heart  itself.    Hut.  in  a.l.lition,  we  nrof;- 
mze  that  by  .lire.t  stinuilus  fr.,m  within  the  heart  itself,  an.!  whollv  .-ipart 
r,m.  this  con.lu.-t.ve  systeni,  tliere  niay  arise  a  series  ,,f  in.lepen,l.-nt  n,M- 
tra,ti„ns,  wheth,-r  of  the  auricular  or  .>f  the  ventricular  muscle.    Tlu- 
out,„me  of  these  investigations  has  resulted  in  a  mass  of  observ.ti,.ns 
more  particularly  upon  the  various  phases  and  forms  .,f  canliac  irn  u- 
larity observations  .so  recent  that  much  has  still  to  be  clarifi,.!,  hut 
luvertlieless,  tcrtaiii  points  stand  out  ch-arly. 

Heart  Block.  .Just  as  experimentally  it  is  possible,  bv  injurv  t,.  tlif 
aunculoventricular  n,.,!ean,!  its  branches,  to  bring  ab,.ut  inconiii.a.ion 
l.etwe,-ii  auri.-l.'s  an.l  ventricl.-s,  so  a  like  incoordination  is  fouf.l  bv 
elinicai  an.l  aut..j)sy  stiulies  to  result  from  .lestructive  disease  aflVrting 


UK  ART  BLOCK 


370 


iIm  M...K'  mill  hiindle.  Tlu-  cnnditioii  Ims  Ihm-ii  known  for  some  vcnrs 
\uiiuToiis  casrs  liavr  l.trn  .lrs<Til.."(l  in  which,  often  siiil.lrnlv,  the 
|Hil..>  hill]  tallni  from  the  normal  70  or  NO  f.  :;()  or  less,  tht;  fall"  l)i-iii(,' 
^(""iiipaiiu'il  l.y  syinptoMis  »,f  an  i-pilcptic  tMu-  (Stokes-Adams  svn- 
'Iroin.i.  It  IS  iii«..nion>lysn;;geste<l  that  Xaj)o|i'nti's  ••epileptic"  attacks 
111  \i.w  ot  his  habitual  pnlse  rate  of  40  or  oO,  were  inanif.-stations  of  this 
'liMUse.  In  many  cases  this  lira.lycardia  or  slow  heat  has  jursisted  for 
vr.irs.  Otiier  cases  have  heeii  noted  in  whicli  the  condition  comes  in 
|.;imxysin.s.  The  more  recent  em()loyment  of  phlel)o>;raphs,  with  record 
nt  tlic  venous  pulse,  has  shown  that  in  these  cases,  while  the  ventricles 
,irt'  -Jowcd  tlu.  auricles  retain  their  normal  rate.  The  various  grades  of 
tlii>  heart  block  may  show  themselves  either  as  ( 1 )  u  leiiftheninK  in  the 
interval  I.etwceii  the  onset  (.f  anriiiilar  and  ventricular  svstolcs.  (l>)  an 
nrr;iM(.nal  veiitricular  dropped  heat.  Ct)  peri.Mlic  dropi)e'd  heats,  every 


Fio.  ISO 


>.".iilt.,n..Hu,  IrminK,  of  the  jUKulo.aroti,l  ami  radial  pulso  waves.     The  .liiiKram.  oonstruete,!  fro.,, 
.•    .  V.  I.:,  re,-.,r,l.-.l  ,i,  the  traeings.  shows  that  no  »timulu«  pa«8..»  aloUK  the  n-p  fihres  to  the  veii- 
I'l'  I's,  l.iit  that  (here  is  eorntilete  ilissneintinn  of  ihp.  vot.tr;....,....  r,..-., i-    t-  \  *___     ..  .      . 


"      •••"•"e.'^'    o..v/nn     luuv     UU     eillllUIUF*    paaSCS    aiOlig 

ui  that  (hen-  is  eornplete  liissoeiation  of  the  veHtrieular  rhvtl,m  ( 
idil'.nn  ami  Kiiehie.) 


r.  S.)  fro,,,  the  aurieular 


i'tli  urniiifl,  pulse,  etc..  hein^'  wanting,  until  there  may  he  devdoped 
'  "'"litiun  known  as  two-one  rliytlim.  or  three-one  rhvtlim,  the  auricles 

ini.-  twice  „r  three  times  the  rate  of  the  vtMitricles,  or,  lastlv,  com- 
'f'^  liciirt  hiock,  so  that  there  is  no  relationship  hetweeu  the  two 
:•  iiiMis.     Here,  with  entire  failure  of  transmission,  the  ventricles  may 

It  tor  years  with  an  inherent  or  idioventricular  rhvthni. 

Other  Forms  of  Anhythmia.     The  time  is  not  yet  rij)e  for  a  complete 

-  ifu  atiui,  „t  tile  arrhythmias.    Some  of  these  are  clearly  of  external 
'  r>  "II-  »rv^\u.    Thus,  in  those  recovering  from  acute  ilines.ses,  there 
marked  cliansres  of  pulse  rate  which  clearly  are  associated  with 


ii:;.,    i 


'   i'lrMtory  act.    These  appear  to  he  of  vagns  orifrin.    Experimcnt- 

■I  '  ail  1..;  sl,.,uu  that  vas^'iis  stimulation  either  mav  hrlng  the  heart 

itii'Istili,  may  slow  the  heart  rate,  or  may  so  act  upon  the  con- 

in  ai)i)aratus  as  to  arrest  the  passage  of  auricular  impulses  to  the 


.ISO 


riiK  <\\unin\  \srn..\u  sysTf-:.\f 


Vfiitrule  Hut  otlu-rs  an-  .iss,«ia;oil  uith  <nn,litini,s  in  tlio  lu-art 
its,.|t.  an.l  •III,-  t..  sorii,.  f„riM  uf  irritatinii.  \Vhi|,.  tlir  h.-art  mus<le  is 
insnisitivo  tuaiiy  stiimii.is  n-arliin^r  it  ,|„riii«  t\w  prri.Ml  nf  .•,mtracti..n 
It  rrs|M,n,ls  to  stmuili  r.a.l.ii.K'  it  in  tlu-  .iia>to|i,-  pluis,-.  \\V  thus  ,nav 
<«.n..-  a.r..ss  n-Kularly  „r  irnrularly  int.ri.ose.i  hrats  ui.rrlate.1  t..  th".. 
nuuiar  rliyth.n.  1  h.-st-  hn.ts  may  be  int.T|,„sf.l  in  tlu-  n .ntricl.-  alon.- 
cii  Ml  tin-  auriclf  aioni-,  or  in  Imtli. 

WbriUation.     What  may  hv  r»Kar.h-.l  as  th.>  .-xtren...  conrliticn  .,f 
irn-jrular  y  uit.r|.ns,..l  luats  is  th«-  cou.litiun  of  fihrillation  or  delirium 

'."  V'a  ■  ""^""''  "*'  "  '"'"'  »""*'''"«  '•••uolarly  through  tht-  h.art 
'nusd...  ,hthT.i.t  arras  of  thr  .uumI,.  arr  s.m  to  hv  .•ontractinK  in.l.- 
pru.l.utly.  so  that  th.n-  is  •■  .•ontraction  of  the  h,-«rt  as  a  wholf  hut 
tlir  or^an  pa>s,.s  into  a  n...  ..ion  of  proKn-ssivily  incn'asin«  (lihitatiou 
with  an  cxtraonhnary  fil.rili.ry  niovfiiu-nt  ..f  the  wliolf  surfarr  ' 
appvaraiKTs  surj,  as  iniKJit  h,-  ^'ivi.  In  a  mass  of  snail  worms,  ,it.ns..|v 
pa.k...|.  wnwlin>r  a.tivriy  in  a  thin-walhMl  !„,«.  Where  this  .on.lition 
a   e,ts  the  v,.ntri.l.s,  unless  it  l,e  imnie.liateiy  arrested  l,v  v«lmis  „r 

:•*'"■.'■  »/•/ *'»•  .f'-^V'^  ■'  •'*""^''-  "•"'  ^'"'^  '"•••""■^''  tl»'  '•irnihitioM  u 

M.evital.ly  arreste.  .  It  seems  pr..l,al.le  that  this  ventrinilar  fil.rillafion 
is  a  cause  of  su.l.lni  death  in  some  <oii.liti(,ns  of  lonK-eontimied  and 
Urave  eanha.-  irre^uhrities.  One  of  the  most  interestini;  of  recent 
o hservations  on  tli.^  heart  is  that  in  eases  of  ohstruetive  eanliae  .lisea.e 
tluTe  may  he  .iilatation  an.l  fil.rillation  of  the  ./„r/V/r.y.  persisting  for 
months.  It  n..t  for  y,.ars.  Hoth  l.y  ^tudy  o»'  th.-  venous  ,,„|se  and  hv  the 
eardioKrams.  tins  ta.t  is  now  well  ..stahlished.  It  is  hut  another  .-or- 
hrmation  oiht.  pomt  made  at  the  l.ej;iuninK  of  this  .-liapter,  that  from 
the  point  of  vuu  .,(  the  i.iimpin^.  action  of  the  heart,  the  auricles  are 
not  e>sentiai.  hut  simply  s.-rve  as  reservoirs.' 


THE  PERICARDIUM 

From  this  point  on  we  shall  in  due  order  pass  in  review  the  main 
features  of  the  morl.id  anatomy  and  histology  of  the  different  organs. 
It  woul.  I..-  well  to  say  here  a  word  or  tw<,  reKardiiiR  the  svstem 
employed  A  .lefinite  order  will  he  preserved  in  eonneetion  v  itli  each 
section,  the  treatment  heinji  as  follows: 

(\)  AbnormalUlr.,  (2)  Clrruhtun,  i)is1urh„ncp,,  (;i)  1,,/lamwntnm, 
(4)  l(c,/n:s.i>er  I),d„rh,i,„rx  (deKencration>,  infiltrations,  necruses, 
traumatic  disturbances),  (.-»  !'ro!,rc.s.ve,'  Disturbances,  including  new 
growtlis,  (h)  .  /,,/  run(liti„„.s  tint  combui  inuirr  the  ah<,vc  headiiujs.  It  will 
be  understoo.1  that  where  any  one  of  these  headings  is  passed  ov.t, 

th,'.  Tll!."!;''i;,'  ^'•'■''1  "'",'"  "'<f  ■'^"'•J''''*  i'*  ''.V  '''hon.as  I.rwi^,  'The  Mechanic,,  of 
ar.  .,  i,  f,  M Vi  V"I'.  Viu^''-'"'  ^  ^""''  ^""-  '^'•''''"'-^  "Pon  the  same  Mil.i.rts 
«"rk    .     ,  "  '"'"'  •,^'"""',  '  '""'  '*■'*''■'■  ""J  MeCrae's  .Systems.    The  .l.-inil 

Of  (<|.ul  imporlanee  ,s  his  '■JXse;.  ■•,  of  the  Heart,"  Lon.hjn,  190S. 


m->: 


-■•i      '  H""  'i'^^BTS"* 


TIIK  PKlili'MHtU'M 


.JSl 


nn  .list.ir».,u.c,.  ni  this  parti.iilar  ..nLr  is  .I,ti:»-.I  nntrxv..rtl.v  in  o.n,,,.  - 
tn.ii  witli  till'  nrpiii  iumKt  coiisidrnitiDii. 

ir.  the  seconcj  phur.  lu.t  in.T.-ly  for  .■conomv  „f  spa<r,  hut  al.M.  as  a 
-lu.^  lu.-ntal  .-xm-is,.  ,t  is  takni  f..r  Kra,.tf.l  that  tht-  n-a.hr  is  fainiliar 
«ith  the  .nam  inorhi.l  processes.  Thus.  »„r  exaniphs  in  nntiriK  the 
.M.tcr.ci  of  (liphtlu-nt.e  or  <atarrhal  iiiHamn.atio,,  of  a  uiveri  surface 
It  .>  not  .  .ouKht  necessary  t..  enter  into  a  .letaih..!  <h-scription  ..f  these 
t.v  IMS  ot  .  .famn.ation;  at  n.ost.  any  .lepartnre  from  th.-  onhnarv  tviH' 
uill  he  note.!,  toK,.ther  with  anv  ,M-culiariti..s  in  thcKrossapiH-aranceof 
the  iittccted  parts. 

Am.I.  lastly,  it  mnst  l«.  clearly  nn.l.rst that  the  trcatn,ent  is  not 

iMt.  n.lc.1  to  l,e  exhaustive.  Our  ol>j,-ct  is  to  pass  in  n-view  these  con- 
.lith.ns  with  which  the  or.linary.  as  .listinct  fr.,ni  the  advance.!,  student 
'Miylit  to  lie  tanuliar. 

With  these  prefatory  n-marks  we  now  pass  on  to  the  pathological 
!i'l  liisto|o>;ical  anatomy  of  the  pericanlium. 

AbnonnaUties.-There  is  only  ,„».  noteworthy  ahnormalitv  of  the 
l>«  ri.„ni.uni.  and  this  is  rare,  namely,  the  con.lition  of  defe<-t.  either 
l'..rtial  or  complete,  of  the  parietal  lay.r.  resulting  in  eith.-r  a  passace 
'T  .•nmnmmcat.on  between  the  peri<-ardial  and  left  pleural  sacs,  or  in 
iNe  h.art  lyint'.  as  it  were,  naked,  in  apposition  t..  the  left  Imiu 

Circulatory  Disttubaiices. -All  serous  surfaces,  from  the  similaritv 

Imt  strncture.  show  «  similar  succession  of  changes  associatcl  with 

'I  liTcnt   grades   of   circulatory   aial    iiiHammat<.rv    .lisorders      The 

i'  "JM.  ant  network  <.f  capillaries  situated  immcdiatdy  umlerneath  the 

;•  M.;.l    n er  renders  them  all  pc-iiliarly  liable  to  present  profound 

irl-         I '".      '  I*"'*  '''"*■*''  "*  '"''^  '""'^''•"  '''•  »>«''l''"'tl.v  encounter 

r.  .niial  pctcchue   duo  apparently  to  irregular  and  .spasnuKlic  lu  .  t 

""N  ."    he  agonal  perio,l,  with  consc(,«ent  .listension  an.l  rupture 

I    ..„,   o    the  poorly  suj.ported    uperficial  capillaries.     Tin-  hin.ler 

v< .  t  of  t'le  heart  is  a  not  infreque.t  seat  of  these  pctechiie.    ( Vrtain 

X .   M.hstances.  phosphorus,  and  the  like,  are  peculiarly  apt  to  lead 

"  'I'-,  multiple  small  hemorrhages,  secondary    it  would  appear   t 

-  - -n.  -on  o    the  capillary  endothelium.    -  .y  may  apji'ir!  that 

•  ■''i'a;;;t';;.irtu;  r"'' '"'  "'^"  '"""^  ^'-^  ^""^^^  ^^  -"^^^ 

'  n.muhtfr'?""-^"!, '•';'•"  T''^*^^'""''^  '-^  i'..vdroperi,.ardium.  with 

I „   ,;""/'"  ;:^'17^.'"  t''«^  ""••mally  there  is  present  a  small  accumu- 

•';'       >  n,us  f,;:id  (Iron,  10  to  20  c.c).    In  obstructive  heart  .lisease 

"-..It  becomes  greatly  mcrease.l  (frcm.  100  to     .  nmch  as  1(K)0 

■u    mtercstmg  point  ,s  that,  despite  this  large  amount  of  Huid, 

pressure  It  brings  to  bear  upon  the  licar.    there  mav  be  ^',is 

.     .  .rmnulat.on  ot  fluid  without  arrest  of  the  heart  acti*;...    \,  ith 

.r,Hl  ,  I  pounng-out  of  the  fluid  there  is  expansion  of  the  parietal 

^ ;;,■";■'"*■•  ^V  yiat  the  pressure  does  not  rise  sufficientiv  high  to 

:     -  tut  auricles,  and  so  arrest  the  onflow  of  blood.    This  con- 


I'^zjr^vKimsisn- 


382 


THE  CARDIOVASCULAR  SYSTKM 


llij 


<Iiti()ii  of  Iiydropmcanlium  is  the  nsult  of  obstructive  heart  and  hmg 
disease,  and,  as  such,  is  associated  with  the  transudation  of  fluid 
Hito  the  other  ravities  of  the  body.  It  is  sifjnifirant  that  there  is 
no  constant  relationship  between  the  extent  of  the  accumulation  in 
the  pericardial,  i)leiiral,  and  peritoneal  cavities;  there  is  considerable 
variation  in  the  relative  amounts. 

Hematopericardium.— Ilematopericardium  results  (1)  from  extreme 
dilatation  of  the  pericardial  capillaries,  with  hemorrhage  from  the 
same,  (2)  from  trauma,  C?)  from  rupture  of  the  heart,  or  (4)  rupture 
of  the  first  i)art  of  the  aorta,  either  from  a  simple  or  from  a  dissecting 
aneurysm.  In  the  first  of  these  cases  tiiere  is  a  combination  of  hydro- 
and  hematopericardium,  and  the  condition  is  not  necessarily  fatal.  In 
the  last  two  the  suilden  outpouring  of  blood  into  the  pericardial  cavitv 
prevents  gradual  and  adaptive  expansion  of  the  parietal  pericardium 
and  the  pressure  may  become  so  great  that  the  accumulation  of  blood 
is  in  Itself  the  cause  of  death  by  arresting  heart  action. 

Anemia.— Anemia  of  the  pericardium  coexists  with  anemia  of  other 
organs. 

Fig.  187 


A  -  -  *t   , 


I .._ . 


S...t„,n  fr„.n  r,,s,.  of  nvurnnt  prri.ar.iitiB:  «,  n,,vnrnnli,im-  h.  e,  layor,  of  ronnertivo  tis«u,..  (he 
rosult  ,,f  pr,.v,„„s  attacks  of  ii,Han,,„„tion;  ,-.  .i,.„„.,it  of  fit.rn;.  the  rr.sult  of  reoont  acutt-  .nfluM,,,,:.. 
tion;  ,/,  tl,<.  hinit  of  the  norii  u'  conno-tive-tissue  layer  of  the  pericanlium. 

Inflammation.— Pericarditis.-  The  first  stage  of  an  acute  inHaniimi- 
tion  of  the  pericardium  is  charactt-rized  by  an  intense  congestion  of 
the  superhcial  vessels,  with  erosion  and  destruction  of  the  eiidothelinni, 
tollowec  by  slight  formation  of  fii)rin  on  the  surface.  This  stage  in 
which  there  lias  so  far  not  been  much  fluid  exudation,  is  characterized 
clinically  by  the  i)resence  of  friction  sounds  or  rubs,  the  roughened 
surfaces  of  tlie  epicardium  and  parietal  i)ericardium  rubbing  one  against 
the  other.  It  is  rare  for  this  dry  form  to  continue  more  than  a  few 
hours;  more  frequently  it  gi\cs  place  to  a  serofibrinous  pericarditis, 
with  disai)p."arance  of  the  friction  sounds.  In  this  form  there  beconirs 
fievel()ped  a  layer  of  fibrin  on  both  the  perican'-'il  surfaces,  wliich 
sometimes  assumes  a  great  tiiickness,  and  through  the  constant  move- 


THE  PERICARDIUM 


383 

->Mn,in,^  often  .  SX  So  '' L    f    l]',"'""  f^'^'^-^'  ""'»  villous, 
I" <•"  quicklv  puIIH  apart     F^hrin       "       '•''  ?'''"  *'"''^'  '"^'^''^  ^'^^^e 

tl:-  -uter  cases  of'  tZre^  o  ^of  h"errSL"Te  ""^'  ?  ^'^"  '" 
<xtr(inc  that  in  place  of  a  simnirjl  P^^^^f^'"™'  t'>e  congestion  is  so 
infl.m.nuition.  ^''  '"'"'"'  "-""^^^^  *here  is  a  hemorrhagic 

-'•■'.I  with  infection  and  btter'Jad;;:  to  "  '"'•""*'"?:  «^^  *''"*  ^^ 
or  a-ain  it  irnv  h^  ,J  1 V  •  I    ™    '•     '*^  *"  organisms  of  low  virulence 

son.;;7:it'lr  ormt  oclTerS^^^^^ 

tn  tlu  ,.ericardium    ^''''"'**^^  ^  '^^  t'^^  extension  of  malignant  growth 

mi.ro.;p„  i  rjlaite  i^c  .1°'°''";^  "'t''""^'/  occasionally  odier 

'-'.';''  <avitv1s  fo.ind1l?eci\SThic'k  U"  ""  '°™"'  ''''^  P^"" 
"-.  r^ir^STnt'S;:;;''"  ''"^'  fibrinous-pericarditis  may,  if  of  only 
'i-'M  .    t  K  fib     '     if  r  '°'"^'fl^'  resolution,  with  complete  absorj- 

•'-  '••.- Ptt  s'  not\a;i:e7:i  or  i  r^"f  '^  ^*-^"  '^^*'-'--  -*h- 
"r..mi.ati:,„  ensues    vh  the  1  T'^''  ''""-V."^'  ^"^'  '"  '*«  P'^^^ 

fil-M..us  layers  rndrepWnTet'o7hrfir-'''"r'^'  ^""^'^  '"*"  *'- 
'i-,..    While  in  the  acut    stTp  f  J  j^  *""   ^^   "^'''  connective 

^""1  l.^   sernni    in  Z  ^   ,*¥  "PP"'''^  '^J'^f^  of  fi'>rin  are  separ- 

^'•'-rl>  ,i    3;i    s  th   P'""^*'^%'^    ''^^""S  the  excessive  fluid  becomes 

V.I  ruiar  ,M,I  thon         ^  .^       -^  organization  continues  there  is  first 

^^''i'l""av  be  either  r«nocri;;«1         V       *''*'  ''"■.^  'developed  «r/^r../o«,, 

"P-..n,.rth,.u  „  he  fo rn^^o'fibro;.rF  .  ''""!?''  '"  '^'  ''^'"'^  "^  t'^^ 
^'"'n.  !<■.   or  W  nnK  ™  ?."    ''''.'"'''  "'  (''^  Keneralized  o^er  both 

•"^■"1  i^  simprSc  perie"d?tir  «  ^'"^  continuation  of  an  acute 
"•""  '""^  are  lot  n,T  ,**"""'*'*"•  «"*  ""ce  formed  these  organized 
''""'■  '"  ZS-.  but  Pf™? '•^"*;.«t  «"toP^v  we  encounter  «of  a  r^ 

i"'i.l. i  np.:  rthUenTm^        "  '""^¥°"  "^  "^"^^  Pericarditis 

^""■^    '^ilanimaion      Th?  "'  P^Tuar.hum.  the  results  of  pre- 

"mation.     This  recurrent  pericarditis  may  be  met  with  in 


384 


THE  CARDIOVASCULAR  SYSTEM 


i  I 


m 


recurrent  acute  rheumatism;  not  infrequently,  however  careful  e  cam 
ination  will  show  that  we  deal  with  a  tuberculous  affection.  While  wi 
may  encounter  the  more  acute  form  of  tuberculosis  of  the  pericardium 
with  abundant  recojinizable  tul)ercles  throughout  the  thickened  peri 
cardium,  it  is  fretjuent,  in  cases  of  tuberculosis,  to  find  few  tubercles  oi 
caseous  areas  proper,  but,  in  the  main,  a  difl'use  extensive  connective 
tissue  formation,  the  fibrous  tissue  being  laid  down  in  regular  layers 
which,  toward  the  free  surface,  give  j)lace  to  a  recent  fibrinous  peri- 
carditis (see  Kig.  1S7). 

SjiphilHiv  Periranliflti.-^  This  form  is  not  frequent.  It  appears 
generally  as  a  continuation  or  extension  of  syphilis  of  the  heart  musclt 
with  formation  of  adlicsions.  Actinomycosis  is  as  rare  or  rarer.  Uvtv 
may  be  noted  the  condition  of  indurative  mediastinopericarditis,  a  con- 
dition in  which  the  inflammation  of  chronic  type  with  adhesions  extends 
into  the  surrounding  mediastinal  tissue  aT'.d'pleura,  and,  with  the  con- 
traction of  the  ti^Mie,  is  apt  to  pull  upoi,  and  distort  the  heart,  giving 
rise  to  aberrant  nuirmurs  and  paradoxical  pulse. 

"MillcSiJots/'—Tn  this  category  also  belong  milk  spots.  These 
are  localizetl  patches  of  thickening  of  the  epicardium  seen  most  fre- 
quently upon  the  front  of  the  right  ventricle;  they  may  be  present  also 
at  the  back  of  the  ventricles,  and  less  commonly  over  the  auricles.  They 
are  slight  overgrowths  from  hypertrophy  of  the  epicardial  connective 
tissue,  and  appear  to  be  induce*!  by  the  rubbing  of  the  heart  wall 
against  the  parietal  pericardium  in  cases  of  <lilatati()n  of  one  or  other 
cavity. 

Etiolocv.— A  wor<l  or  two  may  be  said  regarding  the  causation  of 
pericarditis.     It  apjjcars  probable  that  there  is  no  such  thing  as  true 
primary  idiopathic  iiericardi  's.     The  organism  setting  up  the  inflanniia- 
tion  must  reach  the  i)art  he  -.   some  focus  elsewhere.    Cases  are  either 
of  licnmtonnioii.i  origin,  the  infective  agent  being  brought  by  the  blood, 
or,  more  frecjuently,  deri\ed  hy  r.rteminit,  and  secondary  to  inflammation 
either  of  the  heart  muscle,  of  the  pleura,  or  the  diaphragm.    As  already 
indicated,  a  great  number  of  species  of  organisms  may  be  isolated  from 
instances  of  one  or  other  type.    It  deserves  note  that  tuberculous  peri- 
carditis is  found,  upon  careful  examination,  to  be  more  common  than 
the  naked  eye  apearances  would  suggest.     Lastly,  the  frequency  of 
pericarditis  in  elderly  individuals,  victims  of  chronic  nephritis,  deserves 
mention.     The  conditions  here  are  generally  of  the  serous  type,  and 
frequently  on    bacteriological  examination   the   results  are   negative. 
VNhether  wc  deal  with  a  toxic  pericarditis,  or,  as  appears  to  be  the 
case  also  in  acute  rheumatism,  the  causative  agents  are  such  a>  do 
not  grow  easily  upon  the  ordinary  media,  is  a  matter  which  has  still 
to  be  determined. 

Regressive  Disturbances,  -  Of  these  only  one  conditioi?  de-erves 
note,  namely,  that  of  serous  atrophy  of  the  pericardial  fat.  In  -eiiile 
conditions,  as  also  following  exhausting  diseases,  the  fat  of  the  fiit  ( ells 
may  become  replaced  by  serous  fluid,  so  that  without  much  shriiilvage, 


MYOCARDIUM 


385 


growths  verycon..„o„.  th:>uKh  tli:!:' ^a! '^^ h^•^xL::J,^'"''T;: 
.xan.,.le,  -n  cases  „f  mediastinal  lymphosarcoma.  .>r  M  n  ct"     '^is    ' 
(  ases  ot  cysucercus  an.l  echinococcus  l.v.lati.is  have  been'escribed. 

MYOCARDIUM 

•    K     ,hv^e  t  em  .„t..  four  main  groups:  (,)  thosraCng  the 
trunks,  duet,.:  arteri:;::^  eu  '"  '"""  ^""""^  «"^'  ™«'"  «^t^"al 

^•■p'liiii   i /, I  tl„.  ;.,♦„-,      4.  ■     1      '  •    ^"^^^  («)  the  interauricu  ar 


386 


THE  CARDIOVASCULAR  SYSTEM 


is  the  commonest  of  all  ahiiorniaiities  of  any  organ.  In  Montreal  we 
have  fonnd  it  thus  patent  in  14.5  per  cent,  of  our  autopsies,  and  believe 
this  to  be  an  understatement,  as  frequently  the  oblique  channel  is  so 
small  as  only  to  admit  a  fine  probe.  At  other  times  it  is  large  anu 
conspicuous,  there  being  various  grades  up  to  complete  al)sence  of 
septal  development,  up  to  the  condition  of  cor  biventriculare  triloculare, 
with  a  single  auricular  cavity.  Often  this  condition  is  accompanied  by 
no  physical  signs  or  symptoms,  but  aberrant  murmurs  have  been 
recorded,  together  with  the  <levelopment  of  cyanosis  when  the  pul- 
monary circulation  has  become  obstructed. 

The  interventricular  septum  tlevelops  from  below  upward,  and  here 
again  various  grades  of  defect  are  on  record,  from  total  absence  (cor 
biatriatum  triloculare)  down  to  a  minute  orifice  in  what  is  known  as 
the  "undefended  space"  in  the  upper  portion  of  the  ventricles  imme- 
diately beneath  the  semilunar  valves.  The  indications  are  that  in  these 
cases  the  current  is  from  the  stronger  left  ventricle  into  the  right,  with 
secondary  hypertrophy  of  the  right  ventricle.  Here  again  there  may  or 
may  not  be  cyanosis,  and  the  development  of  a  systolic  murmur  heard 
to  the  left  of  the  sternum  about  the  third  space. 

Both  in  the  auricles  and  in  the  ventricles  are  found  occasionally 
accessory  imperfect  septa. 

3.  Originally  there  is  a  single  primitive  arterial  trunk  which  in  very 
early  embryonic  life  becomes  divided  into  two  great  vessels  by  the 
development  of  a  septim.    There  may  be  (a)  complete  absence  of  devel- 
opment of  this  septum  (persistent  truncus  arteriosus),  this  common  vessel 
giving  off  the  pulmonary  vessels  and  continuing  as  the  aorta,    [h]  The 
commonest  abnormality  is  deviation  of  the  septum,  so  that  we  obtain 
various  grades  of  irregularity  in  the  origin  of  the  aorta  and  pulmonary 
artery  uj)  to  conditions  in  which  the  aorta  originates  from  the  right 
ventricle,  the  pulmonary  artery  from  the  left.    Or  (c)  the  septum  leads 
to  an  une(iual  division  of  the  trunk,  so  that  one  artery,  most  com- 
monly the  pulmonary,  is  minute  or  obliterated  (congenital  pulmonary 
stenosis  with  atresia);  rarely  the  origin  of  the  aorta  :jhows  the  same 
character.    These  conditions  may  be  produced  either  by  mere  vice  of 
development,  or  by  intra-uterine  inflammation.    In  pulmonary  stenosis 
compensation  is  obtained  by  persistence  of  the  widely  patent  ductus 
Botalli  (or  d.  arteriosus).     There  may  also  be  dilated  bronchial  arteries 
aiding  the  pulmonary  circulation.     It  is  these  cases  of  pulmonary 
stenosis  that  present  the  characteristic  picture  of  congenital  cyanosis 
(morbus  cseruleus). 

Intimately  associated  with  defects  in  development  of  the  aortic 
septum  are  abnormalities  of  the  pulmonary  and  aortic  semilunar  cusps. 
These  cusps  originate  as  four  cndocanlial  cushions,  two  of  wliich 
become  subdivirled  in  the  descent  of  the  arterial  septum,  so  that  normally 
six  cusps  are  developed,  three  in  each  artery.  There  may  be  increase 
in  innnber,  such  supernumerary  cusps  being  more  frequent  in  the 
pulmonary  artery,  or,  on  the  other  hand,  decrease,  a  bicuspid  contlition 


^^J9 


>^ihi*iiii^>?«*'  '^^aae^^Bann?- « 


MYOCARDIUM  gg^ 

of  the  pulinonan'.  or  tifn,;,,  „(  *i 

ti.-"sps,  the  result  of  postn;u;;iXI;;;;l-;r"'^'^^*^  ^^"'"  ^"-"  ^^ 

'-rt.r  hypoplasia  of  the  aorta  am  1m  ""''TT''  ''"^''-tation  of  the 
•oronary  arteries,  of  the  s  "temic  n^,'''",f  '?,  ""^^j^-  -'•'•'  of  the 
lMmn.f,Hailifetheductus\.r  e^iosns  oi'ni/^fh  ^  P"''"^"^^-  veins. 
■mrta  is  a  short,  thick  trunk  foZ  nn  '^  ''•  ^"''""""'•.v  «rtery  and 
t'-  '.i'"reatior,  of  the  p2onl;v  a^e  rt'o  T'"'/'''V^''  '•^•«'""  "^ 
;■  the  aorta,  below  the  origh  i  t t  L>  ,  k  ' '"'  '"'  ''^  "''  "''' 
''l-<l.  whieh  reaches  the  righ  vLtricle  frn^^"^l'"-.  ^' r'''^'  '^*^ 
tr-mies.  from  the  puhnonar v  ar  ery  Lo  t7e  Y  '"''1 ""''  "P^^'''  ^■^- 
Ttl.  the  pulmonarv  blood  h^-oShWc!^^  i.^T''V'^  ""''^-  ^^ 
•lu.  tus  undergoes  rapid  involution    J^h  ,    ^^'"^  '""«'  ^"^  the 

"ti.."  in  the  thir.1  weJk  aftertr  h  '  Occasion™  i';  ■r^'''^'  °^"*"'- 
r  a,a,„  2)  .,n  undergo  aneurysmalS  S^  \  3)  re^'"'  T''""'' 
•-Pl'toly  absent,  in  which  case  mav  heZ^^LrV^^'''' 
•"itn(iilarsep+uni,or(4)itmavnre^,.,;f  o  "*"""' 'ftt'ct  of  the  inter- 
tion  of  the  aorta  is  the  n  „  e  give,  t^na;  .u  ''»'""»«'""\^""rse.  Coarcta- 
iN.'  .nh  inunediatelv  abo  e  1  e^"^^^^^^^^  '"•  f  ^'"<«'^  "*'  tl'o  descend- 
''r.l,.  it  mav  be  pointed  out     sittf  ""•'"'*""  "'■^^™«'^'-^-    'l'''t. 

^t' -is  is  ti,e  reiult  o   1  ZC    nhe'^i:'?"^  '"'''^  1'^^'  -"'  ^^is 
'"  "■'■  .'Itcred  con,litions  otr^dati  n  h    bt  "    t'""  ""''  '"'''"P*  '^-^^'^ 

•^ tlu.  left  ^  c>ntri<.Ie  reache    tl  t       k  ^  ^^'  "  ''''•''"'*  t''^  '>l"o<l 

^'N  .xtraunhnarv  series  of  an^mnof  e  ,  '^^V'^tre.nities  through 

Circulatory  Disturbance  ^0^^^^^^^^  ^^^  "'.I^'^-  ^N2)' 

"'■1-tnrl.ances  which  mav  result  from  ohi^  T  *  f"*"'"^  '"*  *^'^  ^^'"^s 
^'"-i..  or  its  branc-hes,  mo  eprtS'TTefr^"  "*'''"  ^^^^ 
""  •-  t  that  the  coronarv  vessds  oriSe  «t  r    kI      '''."■' """••^'-    ^''•""^ 
embolism  is  rare    althonk  ZTt  '^"^'"*'*''  ^^  "fe'^i*  ""ffles  to  the  aorta 

'r-'''''-"'tiu.iniStem^^^^^^^  «"«  -««  -d  hav^ 

"'-'^'"■tcd  by  a  thromburforStt    t  ^^*7T^'->''^^»^^^^^^ 
■'-ti.'  ^ah,..     Walized^J^b^ri    the  J'"'"'"'-'"^'  P''^'^^*  "^  th« 
""<"  -"..dary  to  chronnmhrt^ritis^or.    •'"'  ?'"'?''"  •^^■^"*'  "^^^t 
r'  ^-'"'-l*';  (1)  if  the  brand    rsmL^MiS?"*^^^        V''  '"'^^'^ 
'"-Hlf,Vi,„t  collateral  drculati  n      A  TfV    ™ 'f  ""'•    ^here  may 

";"-l^'  Iron,  either  — ^,,1  .,e  obiitlr^t;'       , ^^«'"»t"tion  of  the  heart 
t'H'  r-runarv  art.-  '      "^'teration  of  a  branch  or  branches  of 

:'''*iiHa,;i|,pearsto  „        '*    '"'"'"^^'"r     '    the  same  and    relative 


(ir 


388 


THF  CARDIOVASCULAR  SYSTEM 


Bejresshe   CllM«es.-The   heart   musele  is   verv   suseeDlible  t„ 
Sa    r,.,  i     '■  ™'f'"  "    l"-'*"-'«"e  wasting  disease,  the 

ndaXe'''Lrlh'V:ri:::''e^^^^ 

™  ™,  em    1*1    ,"';■,"'""" "  ■■'  ""  '•""""'■  distnrbanos  t„  I,. 

Cloud,  swelUn,  (,,.  ail)  is  ,„.„,  |,„„ieul,.rlv  hi  eases  „f  hvnennre.i. 

ftt;  ;.;':.':;;?■  "■"'  '"'""-"r  '"""i-'^-  The^entS. '  * 

.    «tln   tl       ,'r"|l'"'*'''"  ""■  """""I  "'■I'  ""^O-  "I".  I»'<  ><"■ 
i;"ili"g  ^aier  "    "  «l>l-«ra.ue  „f  ,„e„t  that  has  been  di,,,.,l  i. 

is  fonn.l'"^!!;'!??  'r  ""•"""'"""""  "'  '!«•  "I"«  '"<>  »e<le„tarv.  ami 
is,  r™?T;,       n     '   '■"?'"■  '•I"""!^  <l«velopme„t  ,,!  fatty 

bands  of  Zst  «,"■'"'""  ',''  ["'  "'"»  »"'  '»""''  IJ™*  between  the 
m  nntritilT  1  A^T  r"'"'  ,""■  "■'''■I'-  Their  ireinee  leads  to 
»ndi  ,  1 Z  ."I"  "*»"«  "'  '"'"'i™  »'  «>>«  heart  musele.  This 
iond,ti„n  appears  to  l>e  a  fre<iuent  eanse  of  the  weak  heart  and  eardiac 


fer-' 


MYOCARDIVM 


389 


iiKoiiipetenfe  of  stout  individimU      T,. 

t.  iHls  to  be  more  involv^S  than  the  left.         "'''"'^"^'^  '^'  "S^'*  ''^^'t 


Yia.  188 


••"■111,,!,  uf  myocardium  fro 


":i»;,!:2,r!r;;zc  :;;:sr" -----■•  - 


f'lo.  ISO 


Via.  190 


I..'i.v,|,.g,.npratio„  of  papillary 
""'-   '      'McGill  Path.  Mus.) 


Fatty   dPKoncratiou  of  hcart.mim»i„  cu 


-'tJ^rs'a'^-»rs£X^s-:te 


'^  ■  '■'.w^ 


390 


THE  CARDIOVASCULAR  SYSTEM 


S';*^'l'"^  *'"*  "'-["T^"*"'  «  Knii.u.,1   api>e.irance  and   j.-Hhui,... 

ee"  c,   t^elVT  ""     ^^"l'""*"  /'--t.     This   cn.litiou  is  1 " 

stu  c„   ti.e  naU-d-oye  exan.u.atu.n  of  the  interior  ,.f  the  left  ventricle 

otsh,.w„,K  Itself  well  in  the  papillary  .nuscles.    The  heart  .mi 

.l^r  '"«''  "  '''"".''^?'  "':•'  ''''>  ■""'''^'-  "^^  that  np„n  pre.ssnre  I  ' 
^Neen  the  hngers  and  thnn.l.  the  tissne  ea.silv  l.reaks  up  sonu-tinas 
".deed  .t  has  almost  a  l.nttery  eonsistenee.  *  In  onr  exp'crie  . 

c  ttuse  form  n.  ^vhi..h  the  whole  of  the  nu,s,.le  has  a  pa  er         .wi 
a  MH-arance.  IS  found  as  a  result  of  c->tre«.e  toxie  eonditio'ns.  the  tl        . 

..  cases  of  penncions  anenna.     In  the  latter  forn.  the  small  are„s  of 
.legeneratum  are  tlu-  parts  farthest  away  from  the  Mood  sm,         tl 
.nusele  ,mme.hately  around  the  tern.inalarterioles  no    he  ng    .volv 


Fia.  191 


lid.   192 


S<rti(in  of  Diyocanlium  to  sli.nv  prri- 
artcrial  fibrosis:  n,  arteriole  with  well- 
iiiarkfd  cmlarteritis  ol.litciar.s;  other 
patehea  of  filirosis  to  ho  observed  in  the 
lower  part  of  tlie  field. 


fk-otion,  through  edge  of  developing  aiea  of  iint,- 
eardial  fibrosis  showinR  the  rardiac  rmsole  fibres 
(.1)  niergini!  almost  imperreptibly  into  the  hvaline 
fibroid  area  (h). 


Amyloid  or  chondroid  degeneration  is  foun.l  in  the  more-a.hanml 
case,s  ot  general  amyloido.s.s.  as  in  long-eontinue<l  ea.ses  of  Pott's  disease. 
A.S  e  sewhere  it  shows  itsc-lf  l,y  a  dqx.sit  of  tiie  amyloid  material  in  the 
m  ,1,1  e  eoats  of  the  arteries  an,l  along  the  capillary  network.  Tin-  so- 
ealle,  Zenker  s,.r  vitreous  degeneration,  or  hyaline  necrosis  of  individual 
muscle  hl.r,.«s,  is  more  comm,)n  than  is  usually  taught.  Notahlv,  it  is 
to  he  found  m  cases  of  nudnutriti,)n  and  particularlv  where  tlicre  is 
blocking  or  ohhteration  of  branches  of  the  coronary 'artery.    31uscle 


?1^® 


V  ^ZJ. 


:,^ip^>2j- *?:-:*iK5--  ^.i^-i. 


A-  YOCARDIUM 


391 


Fill     10.) 


1 1...  are  f<,  .nd  sw..!!.,,  a.ul  l.yalir.e.  with  I.m  „f  .mcl.ar  stain  an.I  of 

rlZni       ■'";  '■""""••  ^:*"«^'^  "*■  ^n>'»«''""'t  »»y  fibrous  tissue 
Fra«mentation.-I„  examum.K  sections  of  the  heart  muscle  it  is  not 

umonal  to  come  across  ahun.lant  fractures,  as  it  mav  l>e  temu'i    h 

tl:.'  .-..urse  o    the  hhres.     Aromul  these  r.o  reacti^•e  d.auKe    '  "  '  I 

n.  c,!    and    here  has  been  much  .iiscussion  as  to  whether  tn-se  J. 

-tdacts  or  the  result  o  agonal  rupture  of  the  fibres,  due.  f<  r  exampi 

t"  a  t.rnunul  state  of  irregular  fil.rillarv  iMirnpu. 

•  oiitraction  of  the  ventricles.    That  it  is 

not  a   mere  artefact  we  are   iiiclinwi  to 

tliiiik  from  the  fact  that  the  condition  is 

ln(|iicnt  in  certain  particular  conditions 

;<l-rit  Ml  others.     Thus,  Landrv,  work- 

iMi;  111  (.ur  laboratory  at  the  Roval  Victoria 

ili-l)ital.  noted   that  it   was   practically 

"mutant  m  cases  of  aneurysm  of  the  trans- 

\<r-c  arch  of  the  aorta,  associated  with 

Mil >rc  ( .r  less  fatty  degeneration.  Ilektoen 
;lMinjriMsl.es  between  true  fragmentation 
in  wliicli  there  is  rupture  along  the  course 
"  ii  lihrc.  and  segmentation,  occurring  along 
tlK'  lilies  (.f  demarcation  between  the  separ- 
iiif  fibres. 

Fibrosis^  We  shall  refer  to  this  more 
piirtKularly  under  the  heading  of  Inter- 
>titiul  .Myocarditis,  noting  here  that  it 
!>  n  trecpient  result,  not  only  of  acute 
'""•""•"atK.n,  but  also  of  degeneration 
iin.l  necrosis  of  areas  of  muscle  tissue 
■\-o,  lated  with  it  we  frequently  get  hya- 
line .liange  (p.  309),  more  rarelv  we  en- 
"'iiiit«T  calcification  (p.  .313). 

"'■re,  as  an  outcome  of  degeneration 
^''"1  '"'rnsis.  may  be  noted  the  occurrence 
'.rupture  of  the  heart.  This  may  follow 
'■'".V  degeneration  or  infiltration,  but 
";;;•■  re,,„ently  is  the  outcome  of  coroJ 
■'r.^  -  isci.se,  with  loealizwl  necrosis.  The 
;;-'  n.,,uo„t. site  is  the  lowest  third  of 
:!:"  ;:S^  -  ^'^"*-    ^^-^  --^ition  may  also  follow  upon  abscess 


W„llof  left  vcntri,!,-  out  into  ob- 
li'iucly,  or  roughly  parallel  to  the 
■i't'rnal  aspoet,  to  show  extensive 
areaa  of  fil.ro.si.;  „,  „rea  elosc  under 
theemioennliu,,,;  6.  areas  in  depth 
o  myoeanliu.n.  (MoGill  Pathologieal 
Museum.) 


m^-M'^^.^mi^F'^«^M?s!¥s^mmi 


n92 


THE  rAnnfftVASrULAR  SYSTKM 


hi,"):      "■""        '"'•  "'  "■""■'l">'iKt.  of  „l,„„„.,i„,;  to  the  onflow  „r 

a...':,!:;,!!;;:  isS:';™''" '  "■  - ^' '"™" "'  »«-i-wi,, 

-'.  \NitliiM  tlu>  lu'iirt  its«-lf. 

tr.  p  n  ,„  tlu.  ,.l,uml,..r  ,,r  c-hatulK-rs  iH-inn.!  the  ohstnu-tio,.'  •" 

W    I  .n.UK'l,  val\  nlar  i.K„„,,„.t(.n(r  iiri.l  reK'iirKitati..i,,  the  rmimtanf 

n  .  IiK-rmsed  activity  ..f  the  h.-art,  .hie  f,  central  nervous  stin.uh- 

iea-^ir?""  ^;"«^^'V^*'  V"'''^-^''"-'"'^  "^  exophthahnic  goit 
heart  has  been  toun.I  (h.tn.ctly  hypertrophied.     If  the  cause  ..f    he 

hroexhJt'^'    ";''•'•■  'f  "'''  '•'  ^''''  J^'"^'^'  fi--^*  t<,  .lihitation  an.! 

1  '  I  fnl  nn!.  T  7*^'f^'''/'.""^-'-<-«>Pi«tlly  the  individual  fil.res 
e     uH^id;  T;  7T''  ""''  'l'^  P^-'-fopfm-d.     Without  taking  up 

i*ere        Vl    ^  t?''"'        ''-VPertrophy  of  particuhir  chamhers  we  n.av 

unt  of  2    ;     '  ^""7"'  '"  '  '^*  '^  '^  ^''^-  ^'"""f'^'-  ^^''i^'''  bears  the 

e    he  I         r"*""^   T";''  "'"^"'■^*   '^'"'^^-^  hypertrophy.     Th„s. 

\M.re  there  IS  stenosis  of  the  aortic  valve  if   ^s  the  left  ventricle   in 

pdrn...u.ry  ohstruction  the  right  ventricle.  ,         is  firsttir^i.^ 

d  1  d    r       I  FT  '""'^T"*  *•*  ^''•^  """^'"  "f  Wood  from  one 

leld   7.  1  ''''"""^•'»'":''^'  "P?»  the  chamber  in.mcHliately  behind.  ,n,.l 

eft  a.  .1  .''^^f  f"P''y-  Thus,  where  there  is  aortic  stenosis,  the 
emntt  [?n  ">  "r  "'"'^8^  '^^P^'-t^^Phy  because  it  atte.npts  to 
hiToi^r  A  "/^''k"'  '"'■"'"''r  """''^"^  ^"^"tricle,  and  this  is  follow...! 
in  courst-  of  tune  by  hypertrophy  of  the  right  ventricle. 

.....uHH,*.       r       '*'-^"'"  ''  ""'  "  progressive  but  rather  a  regr.ssive 

Ik  I".Pa««">K.   we   would   recall   our   contention    that   two 

h  ^       l'  '"''  ^"  '•''  reognized,   a  physiol.,gicaI  distension 

fnllMll  r-r  '"■^■•""P;"'"^^'^  increased  work  thrown  upon  the  h.art, 

followed  by  hypertrophy   an.l  a  pathological  .lilatati..n,  an  indication 

that  the  heart  cannot  fully  res,)..n.l  to  the  w..rk  thrown  upon  it,  a 

condition  in  which  niicr..sc<,,,ically  we  fin.j  that  the  fibres  which  had 

ndergone  a  true  simple  hypertrophy  n.>w  show  regressive  cIkh:.,^^, 

with  s.)ine  shrinkage. 


THE  KSDOCARDIUM  303 

New  Oroirth«.^-I'rir..ary  t„m..p.s  ol    tlu-  rnvo,ar.lium  are  .listinctlv 

I,- ..rally  ,,    „„,|„p.o  „„„„r,  f„„,„l  i„  ^.|,i|,|„,,  J^  ,,r,,\.™ZS 


THE  ENDOCAROIDM 

K-Mlocanlitis  is  s„  ..ftm  confiiu-.l  h.  tlu-  valves  tliat  wIh>m  we  use 
li.s  t.r,„  we  are  apt  to  pic-ture  to  o„rselv,.s  a  'valvulitis"  an  I  hv  a    .,<  i 
-^    '•  ».;rget  that  the  e„.loeanliu,n  i,u.|,..les  the  whol      f  ih         i  , 

i-litt;:;!:;^::::: """ ""  -^ ^  "^"-  ^''"■'  ^"^'  ^•'^'-  --^ 

Abnormalities.  -These  are  rare  a.ul  co„fi„e,l  to  the  valves.  There 
"!..>  ..accessory  semilunar  valves  or  onlv  two;  vers-  rarelx  has  I ».» 
-;-... I  a  d.uble  orifice  ..f  the  ,„itrai;  Abenations  o  u  wn  ," 
"•,";l"'<'a-.  ur..l  cords  ,,ass,„g  from  o„e  papillarv  mus.l..  to  the  th.r 
;mli..„t  to,u.h,„g  the  mitral  eusp  are  „ot\.!ry  .,K..mL  ..  \  st  II  n  e 
;;i'';;.  .al.n,,r„ml.ty  is  fenestration  of  the  semilunar  val  '^  T  "se 
I'n-M  .tu.ns  are  situate.)  .mme.liately  hen  1,  the  free  e.ise  in  tin- 
.T.^M.t  appos.t^^.,.  and  cause  no  functional  disturl.ance  ^ 

n^^^^  Disturbances.  -The  c-in-ulatory  .listurhanc-es  are  of  slight 
1  •.rt.u.e.  llu-  healthy  valves  are  non-vascular,  hut,  just  as  in  J,, 
'HI..,  alter  mHa.nmat.on,  there  is  <levelop„,ent  of  the  n-sse  s  s,  hm 

omas  .  substance      In  mfants  minute  pinhead  hema- 

tlu  UMtral  cusps.     I  he  latest  view  is  that  in  the  course  of  develop 

""t  nnnute  pockets  hec-ome  for„,ed.  lined  hv  emh.thdi  1    wh      " 

;-;-.  n.vcr..d  u.  by  the  en<h.thelium  above!  form  chliiluLc:  t^ 

I  .lno.l      i  hey  are  not   therefore,  associated  with  the  presence 

^  "     i     huA;  S/v'  '^"''":  "^  the  endocardium  occasionally  met 

^^^_^    ;-lm  ^to^hemoglobin  unbibition,  and  is  usually  a  post  mortem 

'"""'nHnM  "'^''""^*^-~'^*'^  commonest  and  most  important 

;     1>  nrbances.  seen  m  connection  with  the  endocardium,  are 

;    m        ed  under  the  heading  "endocarditis/'  whether  acute  or 

Ac  ute  endocanhtis  most  frequently  affects  the  valves,  although 

'       "»;'»''';;-l  that  the  mural  endocardium  ma.;  also  be 

•Hctt     Ji  i,  t     '  'T'"'''"'"  '^^   '-•h'^'iKes  seen  more  particularlv 

■i  vniror  tw;:;:!^"'  "^^  "'^"  '^^  ^"^-""^--^  ^^^^^'"^  *»- 

'-phSlcvH''"'"'  '""T  *'"^*  *he  emlothelium   lining  the 
I^haRocvtic  power    and  can  take  up  bacteria  from  the  blood. 


liH|;i| 

•■lir.  ■! 
ir  ti:i 
iii\..l 

ill  (•.,; 
Wjill. 

i'ix 

lu'iin 


.lot 


THE  CARDIOVASCVLAH  SYSTEM 


1  *^  )^"^»''«"irn,  w,.  may  in.HKi....  that  „t  iM.i.Us  of  .mrnmin 

Otic  Hct.„„  .s  ,„.,st  liM.v  t..  ,Kr„r,  «,ul  sn  tUv  »..ri.-,  I      h     't tt 
...  ru.,.|ovn>tru.,.lur  valve  an.l  the  vn.tru...lar  asin't   7t  e     • ..    . 
valvfs  are  favoral.lr  amis  t<.  this  procNs     H,,t  at  tl ......     r 

>tr.n  ,1,   thr  l.u.tma   ,„   thnr  nu,lti|,li<at ..volvinit  other  <r 

"  th..  nn„u.,l,at..  nnKhhorhnn.!.     Wi,h  this  ,h-stru,-tio„  of  th    |i , 

c.Ntu.t  „»  th.M.  v.-p.tat.nns.     .•  w,-  .l.-al  with  ..rganis.ns  of  „.i|,| 


^.li  i(M 


Km     103 


V.Trui-M...  .■n,l„rur,lit;.,  „f  ,,„r,i,.  vuIvp, 


Aoriii-  (U.locnrdilii  with  vugctaliuii  (,i). 


ami(.ftht'o.ui;,r;r;i;.^:.  •,  ^'''?'^  ^"''  '"'"'^'e  «  relatively  large 

pr ore  s  an,  '  :  r  I  '  "'""  "  r';;^'''  '""^^"  '^  I^--"^"'^  f'"-  the  thro  nhot  c 
f  Sn  tlS  "''"•'^V'"'',""""-'"^'"  vegetations  are  phkIuc-I. 
i  ;.l  le ;  n  e^^Z^^^^  :>r..teolvtic,  the  fil.rin  of  the  ve,,.ta- 

ten  a    r Ire  f  r  •  "  ^'^^^'V?*'"^  ^^'t''  ^^eir  containe.1  bacUria 
ic   ve    „.  ^1!     U  •;."";  ••  '"!:""'  '•'''  ^''^  '''""^^  ^t^'^'^'"'  give  origin  to 
Ilmc  er     i..  ^  ^'  "''^■'■"^"'  ^"^f^^*"  ''^-V"  •'«  expose,!,  and 

.  uKt  ve'r         r^^^  '"*"  *''^'  ^'^'^-^  ^"'^^tance  gL  ri>e  to 

K    .^i  h   V„r      ;  '  f  ^•^'".'"P"">ving  which,  with  thinning  of  the 

ma  DO,  tt       i  "'"T  "'fi^'-^"  ^"?'^  ^^•'^>'  »'"'  'levelopment  of  a„eur^s- 
r nSor  t ,         '      r  ^^f  V^'^'  '"•  ^^'t^'""*  «"^h  aneurysm  there  niuv 

anZ^^  ,1        ^  ^'•"•"^•"'••I'tis  an.l  various  observer,  have  Hifferf.!  .mkH 
aniong  theii.selves  as  to  the  classification  of  these  various  grades. 


-^mm9mmsaBiE^si^z:'if^mm^'^'w^^s^^& 


THE  tSDOCARDIUM 


■  -i^rfs 


305 


h  is  usiml  to  make  ii  hmuel  distinction  lM.fu-....n  (\\  .i».-u 


Fiu.  100 


•it'MMtiv.-  •■n,i„™rf!iti:!  „t  mitral  vi;vr-  vf. 


«ilKli„n  or.  n.uioul»r  surface  .u  «.     tMK.ill  Path.  Mu«.) 
Fia,  107 


■^'■"''■(L.lr:,!  cndoci 


urait«  «itU  rupturo  of  ol.ord*  tendinc:  „,  papillary  mu«le;  6.  rup.u, 


rupturad  chorda 


396 


TIIK  CMiDIOVASClLAR  SYSTEM 


1(5  i 


I        i 


ami  iuconsidtTiiMi'  and  also  tlie  fil)riii  forniatioii  over  the  affected 
areas  is  very  slight  in  amount.  (2)  Vegetative  endocarditis,  in  which 
the  niaiii  feature  is  the  extensive  formation  of  thrombotic  vegetations, 
and  (.'})  ulcerative  or  malignant  endocarditis,  in  which  the  dominant 
feature  is  the  extension  of  the  bacteria  into  the  valve  substance,  with 
necrosis  and  ulceration  and  their  sequ«'ls.  But  while  making  this 
distinction  it  must  be  remembered  that  an  ulcerative  endocarditis 
may  also  be  vegetative,  that  there  may  be  areas  of  ulceration,  and 
surrounding  these  abundant  formation  of  vegetations.  Here  once 
again  we  have  to  recognize  that  we  deal  with  a  succession  of  grades 
of  the  inHainiritory  process,  and  not  with  distinct  forms  of  infiannna- 
tion. 

Ki(i.   198 
U 


I  Iccrativo  cndocarditia  witli  aneurjsiiial  pouchinx  and  perforation  (n)  of  mitral  valve.     The  same 

in  reverae  (k). 

Of  the  different  valves  the  mitral  is  most  frequently  involved  in 
the  acute  jjrocess.  Next  to  this  is  seen  a  combination  of  aortic  and 
mitral,  and  in  third  place  the  aortic  alone.  The  tricuspid  is  least 
frecjuently  involved. 

Chronic  Endocarditis.  —  What  we  said  regarding  the  pericardium  is 
true  with  regard  to  the  endocardium,  namely,  that  we  can  recognize 
widely  dilferent  conditions  which  familiarly,  but  often  fauhily,  are 
included  under  ihe  heading  of  "Chronic  Inflammation,"  namely, 
the  organizing  healing  stage  of  aii  acute  inflammation,  the  effects  of 
a  recurrent  acute  inflammation,  the  effects  of  granulomatous  inflamma- 
tion, and  what  is  not  inflammation  at  all.  the  persistent  remnins  or 
outcome  of  previous  inflammation.    The  result  of  an  acute  inflaniuia- 


^v:M^ 


mf^'^tm^Ms:.  wsmm. 


THE  ENDOCARDIUM 


397 


Fio.   19U 


tioii  is  in  the  first  place  a  liability  for  the  affecte<i  cusp  to  become 
\  iisc-Iarized;  secondly,  if  ihe  process  be  not  fatal,  there  ensue  the  various 
>taKes  ()f  healing,  with  cell  proliferation  and  cicatrization  in  the  area 
lit'  i)revious  acute  infiamnia- 
tiuii.  Thirdly,  the  vegetations 
may  undergo  complete  reso- 
lution or  absorption,  or,  on 
the  other  hand,  the  organiz- 
iiig  process  in  the  underlying 
valve  tissue  may  extend  into 
tlitni  and  they  may  thus 
hccoine  replaced  by  new  con- 
nective-tissue formation  and 
may  become  represented  l)y 
ciHitracted  fibroid  nodules 
l)roji(ting  from  the  surface 
(if  tlie   cusp. 

'i'lic  condition  that  we  most 
fr((|iu'ntly  refer  to  as  chronic 
ciidocarditis  is,  however,  one 
(if  ditf'iise  thickening,  with  con- 
traction of  the  cusps,  leading 
titlipr  to  stenosis  of  the  valve,  with  great  narrowing  of  the  orifice, 
iir  to  incompetence,  with  incapacity  of  the  cusps  to  meet  and  close 
tlic  orifice,  or  often  a  combination  of  the  two  conditions.  As  regards 
the   mitral    valve,    which   is    most    commonly   affected,    it    must    be 


Mitral  incompetrnce  Been  from  b<-low,  to  show  short- 
ening and  tliieltcninK  of  chorda-  tcndinoip  and  largu 
orifice  a,  papillary  muscle  with  attached  chordte  «o 
shortened  that  the  muscle  impinges  upon  the  valve;  fr, 
patent  orifice  of  valve  surrounded  by  greatly  thickened 
iibr  -sed  cusps. 


FiQ.  2(X) 


liiiil     Ml  .-i«:  bniiiin-hole  seen  from  auricular  aspect: 
■'■  ''  ■   -lit-like  opening  hidden  by  fibrous  fold  (6). 


Aortic  strnosin  swn  froni  aliove,  with 
fusion  of  cusps,  leaving  but  a  small  cen- 
tral orifice. 


kfiii 

!)iit 

I'liai; 


Ml 


mind  that  this  valve  is  not  composetl  of  two  distinct  cusps 
a  \eil  of  irregular  depth  hanging  down  into  the  ventricular 
r.    If  we  study  a  series  of  hearts,  we  find  not  a  little  variation 


398 


THE  CARDIOVASCULAR  SYf!TE^f 


in  the  coiiformiition  of  tliis  veil,  and,  as  a  result,  when  this  becomes 
diffusely  thickened  hy  new  fihrous-tissue  formation,  in  some  cases 
the  result  is  a  funnel-shaped  narrowinj;,  in  others  with  contraction 
of  the  fibrous  tissue  there  develops  a  slit-like,  or  button-hole  orifice. 
As  regards  the  semilunar  valves  we  find  that  the  fibrosis  affects 
more  particularly  the  distal  portion  of  each  cusp,  with  contraction, 
the  cusps  become  much  shortened,  so  that  the  corpora  Arantii,  in  the 
act  of  closure,  cannot  possibly  meet,  incompetence  and  regurgitation 
being  set  up.  Or,  on  the  other  hand,  the  separate  cusps  undergo  fusion. 
Where  all  three  become  fused  marked  stenosis  is  the  result  (see 
Fig.  201).  It  has  already  been  noted  that  there  may  be  congenital 
fusion  of  the  cusps,  but  it  must  be  recognized  that  such  fusion  can 
also  occur  as  the  result  of  inflammation.  If  the  inflammatory  agent 
attack  two  neighboring  vahes  in  the  angle  of  origin,  where  there 
is  little  movement  of  the  cusps,  adhesion  and  subsequent  organization 

Fio.  202 


Fusion  of  aortic  cusps.     The  two  cusps  at  a  have  become  united  in  consequence  of  progressive 
slow  inflammation  oricinalinu  at  the  angle  of  junction. 


may  take  place,  and  thus  immobility  of  the  cusps,  with  progressive 
inflammation  involving  the  angle  of  apposition,  may  continue  until 
the  neighboring  cusps  become  bound  together  along  the  greater  part 
of  the  area  of  apposition. 

While  it  is  true  that  fibrosis  of  the  valves  is  a  resultant  of  acute 
inflammation,  we  are  of  opinion  <!iat  in  a  very  large  proportion  of 
cases  the  thickening  of  the  valves  is  more  of  the  nature  of  strain  effect 
than  the  outcome  of  previous  niicrobic  irritation  of  the  valves.  Even 
in  cases  of  mitral  stenosis  tjccurring  most  frequently  in  young  individ- 
uals and  then  following  upon,  it  may  be,  recurrent  attacks  of  acute 
endocarditis,  presumably  set  up  by  the  organism  or  organisms  of  acute 
rheumatism,  there  is  in  general  wanting  any  intimate  relationship 
between  the  site  of  the  lesions  f  the  acute  disease  and  this  chronic 
thickening,  involving  the  whole  area  of  the  valve.  The  even  and  regular 
manner  in  which  the  new  connective  tissue  is  laid  down  leads  us  to 


THE  ARTERIES 


399 


till'  belief  that  through  the  localized  lesion  of  the  acute  disease  the 
\al\e  has  been  rendered  rt '  itively  weak  and  less  competent  and  as  a 
(diisiviuence  is  subjected  ii..\v  to  a  greater  strain,  that  greater  strain 
liadiiig  to  a  diffuse  proliferation  of  the  connective-tissue  elements, 
1111(1  consequent  thickening  and  contraction,  consequent  greater  obstruc- 
■\n\\  and  increased  muscular  action  with  heightened  blood  pressure, 
uit'i,  in  short,  the  establishment  vicious  circle.     In  the  case  of 

tlie  aortic  valv3  this  view  gains  still  greater  support,  and  that  because 
fibrosis  of  the  aortic  cusps  is  more  frequent  in  later  life,  associated 
with  arteriosclerosis.  As  we  shall  proceed  to  point  out  (p.  400),  the 
filin.tic  changes  of  the  aortic  intima,  in  the  majority  of  cases,  bear  no 
rtlationship  to  any  infective  process,  for  it  must  be  recalled  that  the 
aiirtic  cusps  are  merely  infoldings  of  the  cardio-aortic  intima.  As 
actual  or  relative  strain  is  the  cause  of  the  one,  we  must  presume  that 
it  is  equally  the  cause  of  the  other.  Rupture  of  the  semilunar  cusps 
occasionally  follows  such  strain  with  its  accompanying  rise  of  arterial 
lilnod  [)ressure. 

As  in  arteriosclerosis,  so  in  these  cases  of  valvular  fibrosis,  we  are 
a|>t  to  encounter  a  series  of  degenerative  changes— fatty  degeneratioii 
and  necrosis  with  atheroma  and  calcification. 


THE   ARTERIES 


'1  "he  arteries  may  be  divided  into  the  two  broad  groups  of  those 
»(  the  clastic  type  and  those  o'"  the  muscular.  The  aorta  and  its  main 
l.raiiclics  l)cl()iig  to  the  first.  In  these  large  vessels  receiving  the  first 
iMiiiuIsc  of  the  blood  wave,  and  thus  liable  to  sudden  expansion,  some- 
ilnnj;  is  evidently  needed  beyond  muscle  fibres,  both  to  prevent  undue 
(lHtcii>ioii  and  to  bring  the  vessels  passively  back  to  the  normal  when 
the  (listciidiiig  force  is  removed.  We  find  in  the  media  of  these  vessels 
iimltii)lc  sheaths  of  elastic  tissue  alternating  with  layers  of  muscle 
fil)rcs  111  the  media  proper  these  muscle  fibres  have  a  circular  arrange- 
iiuiit.  Iniinediately  within  the  media,  in  what  is  known  as  the  musculo- 
cla>tic  lay(>r  of  .lores,  there  is  to  be  found  a  small  zone  of  fibres  having 
;i  l"iii:itiidiiial  direction.  Smaller  arteries  are  of  the  muscular  type, 
III  whicii  tlic  elastica  is  often  reduced  to  a  single  prominent  layer] 
'"'•iiiiii.U  the  iioundary  between  intima  and  media;  there  is  often  to  be 
iHitrd  a„  external  elastic  layer  between   Jie  media  and  adventitia. 

t  1-  these  smaller  arteries,  with  their  relatively  abundant  muscle 
l^ivr  nid  capacity  to  undergo  relatively  great  dilatation  or  contrac- 
ti'Mi  that  are  the  great  factor  in  determining  the  blood  pressure.  As 
t"  !h.  extent  to  which  the  contraction  and  dilatatitm  of  the  arteries 
i~  '111'  er  the  control  of  the  central  nervous  system,  the  evidence  before 
II-  iiidicatcs  that  the  same  conditions  obtain  as  in  connection  with  the 

""'  namely,  wc  have  central  influences  acting  through  the  vaso- 
L'Hi-Mietors  and  vasodilators;  there  exists  also  a  rich  system  of  nerve 


4on 


rut:  <  \i{i)iov.\scrr..\R  systkm 


cells  with  prr ccssi's,  fdrmiii^'  ii  pU^xus  in  tlu-  arterial  wall,  aiul,  thirdly, 
the  iiuisclc  <  I  the  media  is  toiiiid  to  l»e  capable  of  direct  stimulation 
The  larger  arteries  may  exhibit  strong  contraction  many  hours  utter 
deatii  and  many  hours  after  the  vasoconstrictor  nerves  are  no  loiij;er 
irritable.     Leonard  Hill,  more  particularly,  has  called  attention  to  the 
fact   that,   under  heijfhtened   internal   pressure,   arteries  tend,  not  to 
expand,  but  to  contract,  and  this  so  immediately  as  to  indicate  a  local 
and  not  a  reflex  reaction.    With  regard  to  the  nowrishment  of  the  arteries 
the  vasa  vasorum  penetrate  only  into  the  outer  half  of  the  media,  )■• 
the  internal  elastic  lamina  is  seen  to  oppose  a  considerable  hindr 
to  much  nutritive  intcrchanfie  between  intima  and  media.     We  must 
conclude   that   the   intima   is   nourished   from   the   blood   stream,  at 
least  the  outer  two-thirds  of  the  media  by  the  vasa  vasorum,  while 
the  inner  third  of  the  media  may  i)ossibly  receive  nourishment  from 
both  sources. 

Abnormalities.— We  have  already  referred  to  abnormalities  of  the 
larger  trunks  {p.  :>S('»).  We  may  here  note  in  addition  that  a  general 
hypoplasia  has  been  described,  with  smrU  size  of  the  aorta  and  main 
trunks.  Some  would  regard  this  as  truly  c(  igenital,  and  as  a  condi- 
tion predisposing  to  chlorosis,  general  malnutrition,  tuberculosis,  etc. 
Others  regard  it  as  secondary  to  impoverished  state  of  the  blood,  with 
weak  heart  action. 

Inflammation.— The  arteries  ma\-  be  involved  in  the  inflammatory 
atiections  of  tissues,  their  walls  often  being  erodeil.  That  severe  hemor- 
rhage does  not  happen  more  frequently  than  it  does  is  due  to  the  fact 
that  the  inflammation  causes  a  thrombosis.  Inflammatory  states 
primary  in  the  arterial  wall,  especially  those  due  to  syphilis,  will  be 
discussed  in  connection  with  arteriosclerosis,  by  which  means  that 
imi)ortant  process,  belonging  largely  to  the  regressive  changes,  will  be 
discussed  without  being  divided.  Biirger,  of  New  York,  has  of  late 
called  attention  to  the  frequency  of  an  obliterative  arteritis  (thrombo- 
angiitis obliterans)  among  Polish  and  Russian  .Jews,  leading  to  presenile 
gangrene  of  the  limbs.  Beginning  as  a  migratory  localised  inflamma- 
tion with  thrombosis  of  certain  veins,  eventually  both  arteries  ami  veins 
of  a  limb  become  I'Xtensively  thrombosed.  The  smallest  arteries  are 
free,  and  there  is  accompanying  periarteritis.     The  cause  is  unknown. 

Regfressive  Changes. — The  observations  of  Aschoflf,  Klotz,  and 
Foster  show  that  the  thickness  of  the  larger  arteries  undergoes  pro- 
gressive increase  until  about  the  age  of  thirty-five,  then  remains  sta- 
tionary until  about  fifty  years  of  age,  after  which,  in  the  majority  of 
individuals,  a  reduction  is  to  be  noted.  It  is  the  media  that  in  the 
main  shows  these  changes,  and  here,  after  fifty,  both  the  muscle  fibres 
are  at)t  to  show  l)cgiiuiing  atrophic  disturbances,  leading  to  shrinkage 
and  fiisappearance  of  some  elements,  and  also  the  elastic  sheaths  show 
greater  irregularity  in  contour  and  with  the  disa.jpcarance  ot  inter- 
vening muscle  fibres,  are  apt  to  run  together,  forming  coarser  Uranus. 
Hut   beyond   this   simi)le   atrophy,   in   elderly  people   ve  frequently 


THE  ARTERIES 


401 


(•iiii.iiiitcr  iiulicatioiis  of  Ixttli  fatty  and  calcamms  (k'Keiicratioii  of  the 
iiiiimIc.  often  assc.ciated  witli  a  failure  on  the  part  of  in(li\  ichial  ehistie 
ImimI^  to  take  the  ehistie  tissue  stain,  which  may  he  mistaken  for  rn|)ti!re 
nt  the  fihre-.  All  these  a|)|)earanees  indieate  that  ith  advaneinj; 
iii;.'  tile  wall  of  arteries  of  the  elastic-  type  becomes  weaker.  In  the 
:irt.  Holes  and  smaller  arteries  hyaline  degeneration  is  not  infn-cpient. 
I'.nih  in  the  media  and  in  the  adventitia  there  is  to  be  noted  a  deposit 
or  inliltration  of  a  homoj^eneous  hyaline  material.  Somewhat  similar 
1(1  this,  involving  not  the  ordinary  connective  tissues  but  the  elastic 
ti-iics,  is  the  elastoid  degeneration  of  the  uterine,  ovarian,  splenic,  and 
nili.r  arteries  already  described  (p.  809).  Amyloid  infiltration  has  a 
Iinihlection  for  the  muscular  coats  of  smaller  arteries  as  well  as  the 
iiiitcr  surface  of  the  capillaries. 


203 


Fig.  204 


•ill  -  I 


:ik^  nf  a.irt.T.      (McGill  Piitho- 
loRioal  Muw'um.) 


N'odosp  .irtorinsclcroHis.  Showing  fibroid  dvprgrowths 
of  intimu  anmnil  thn  orifircs  of  the  intercostal  urierics. 
(McGill  I'atholr.niral  Muwum.) 

Arteriosclerosis.— This  condition,  or  as  recent  (Jerman  authorities 
t'lin  It  •  atherosclerosis"  or  "atherosis,"  is  the  most  common  cause 
'it  'i-  ilh,  direct  or  indirect,  in  those  who  attain  to  middle  life  or,  we 
iiiii'  .ly,  after  thirty  years  of  age.  "A  man  is  as  old  as  his  arteries," 
'  i>  incapacity  on  the  part  of  the  diseased  arteries  to  respond  to 
I  '  <  d-  of  one  or  other  organ  that  leads  to  malnutrition  and  atrophy 
"  '  organs,  even  where  graver  and  more  immediate  disturbances 
i  1  produced  by  distension  of  the  diseased  artery  (aneurysm), 
'  'uptiire  of  the  same  (hemorrhage  and  apoplexy).  It  is  thus  all 
'  r!;iiit  to  have  some  general  ideas  regarding  the  nature  of  arterio- 
■■    ■'-  .iiid  the  conditiot  ;  leading  thereto. 

Ill  of  (legeneration,  frequently  observabh'  in  those  dying  from 

•    ii-<  ISC  is  the  i)resence  of  "fatty  streaks"  of  the  aortic  iiitima, 

i'i'iir  streaks,  (lisposed  longitudinally,  jKirticul         in  the  dorsal 

■  'lie  aorta.    Examination  here  shows  fatty  changes  which  mav 

'■'     M'  to  the  intima,  but  xery  frequently  involve  the  cells  of  the 


nil. I 
til, 

nf  I 

11  Pi 

or  i 
imp 

Mi.  I 

A 
ilru; 
wiii; 
I  ml! 
t'\t( 


102 


THE  c.\nninvM<rvLAR  system 


W-i 


musouio-elastio  laytr.  Apparently  this  represents  only  a  transitory 
change,  and  would  ho  rt-coveri'd  from  had  the  individual  himself  recov- 
ered, and  that  because  we  are  unable  to  find  any  chronic  developments 
taking  the  place  of  tht'se  streaks;  Klotz  notes  occasional  intiniai 
thickening  over  the  fatty  areas;  nevertheless  the  disposition  of  these 
streaks  is  obviously  different  from  ll  at  of  the  nodes  in  ordinary  arterio- 
sclerosis. 

Arteriosclerosis  is  not  in  itself  a  degeneration,  even  though  it  may 
give  place  to  degeneration;  it  is  to  be  regarded  as  an  adaptive  process 
following  upon  degenerative  changes  occurring  in  the  arterial  wall. 

Forms  of  Arteriosclerosis. — It  may  manifest  itself  in  more  than  one 
form:  (1)  the  simplest  and  commonest  type  is  what  is  known  as 
nodose  arteriosclerosis.  Tiie  earliest  stage  of  this,  seen  in  the  aorta, 
presents  itself  in  the  form  of  whitish,  flattened,  nodular  thickenings. 
It  is  peculiarly  apt  to  he  situated  around  the  orifices  of  the  aortic 
branches  and  notablv  aroimd  those  of  the  intercostal  arteries  (see 
Fig.  204). 

Section  of  one  of  these  flattened  nodes  shows  that  we  deal  with 
a  pronounced  ihickeiiiiig  of  the  intima,  in  the  form  of  successive  layers 
of  new  connective  tissue.  Where  the  condition  is  more  extensive, 
similar  nodes  are  irregularly  scattered  along  the  course  of  the  aorta 
and  thickenings  of  like  nature,  though  relatively  of  larger  size,  cover- 
ing, that  is,  a  larger  proportion  of  the  arterial  circumference,  arc  to 
be  encountered  in  the  various  main  branches,  there,  by  their  very 
size,  leailing  to  some  narrowing  of  the  lumen.  In  the  earlier  stages, 
as  above  indicated,  we  deal  with  a  simple  overgrowth  or  hyperplasia 
of  the  intimal  connective  tissue.  The  most  abundant  nuclei,  and  the 
best  staining,  are  i)resent  in  the  layers  immediately  underneath  the 
endothelium.  This  indicates  that  these  are  the  layers  of  most  recent 
development.  As  ;.  latter  of  fact,  associated  with  this  develo])mcnt 
of  superficial  layers,  the  deeper  layers  show  evidences  of  malnutrition, 
so  that  very  frequently  we  find  either  the  deeper  cells  swollen  and 
poorly  staining,  or  that  they  exhibit  fatty  degeneration,  with  granular 
breaking  down  an<l  necrosis,  and  often  with  some  imbibition  of  fluid, 
so  that  the  part  is  distinctly'  softened  and  somewhat  (Edematous,  or 
again  this  deeper  intimal  tissue  breaks  down  into  a  porridgy  mass 
of  necrotic  material,  and  if  the  superficial  layer  be  broken  and  the  soft 
material  be  examined  under  the  microscope,  it  is  found  to  afford  abun- 
dant characteristic  crystals  of  cholesterin,  together  with  fat  droi)lets 
and  lipoid  globules,  which  are  doubly  refractive.  Or,  lastly,  such 
atheromatous  areas  become  the  site  of  calcareous  infiltration  and 
deposit,  and  this  to  such  an  extent  that  there  may  be  formed  in  the 
thickened  intima  a  solid  calcified  plate.  The  jjresence  of  such  a  rigid 
plate  in  an  organ  liable  to  some  dilatation  results  at  times  in  the  rup- 
ture of  the  overlying  la\cr  of  intimal  tissue,  and  the  formation,  tiius, 
of  what  is  known  as  an  atheromatous  ulcer.  It  is  interesting  to  note 
that  there  may  be  somewhat  frequent  erosions  and  ulcerations  of  this 


A RTERIOSCLEROSIS 


403 


iii.tiire,  with  little  or  no  thrombosis  formation;  occasionally,  however 
a  wcll-niarked  F)arietal  thrombus  forms  upon  one  of  these  atheromatous 
ulcers  (see  tig.  2()()). 


Flo.  203 


—b 


S.-.tu,ii  tl,r.mKh  a  fibroid  plaque  of  aortic  intima  from  case  of  nodose  arteriospleroois:  a  outer 
pr.l.fcrafuK  lay.r  of  intima:  6,  deeper  hyaline  layer;  c,  atill  deeper  layers  showing  deposit  of  cal- 
lurcoiis  salts  (stained  black)  and  extending  into  d.  the  inner  layers  of  the  media 


Via.  206 


lur,, 
Wl 


'  'I  il.r.,i„hus  (n)  n„d  atheromatous  ulcer  (M  of  ascending  aorta.     (McGill  Path.  Mus.) 

iil'"vc  is  the  (omnionest  t\\w.    The  studies  of  the  last  few  vears 
't  t..  the  recojjnition  of  another  form,  namely,  (2)  the  syphiUtic. 


'>ii'  n ,,.  ,i„,  tormer  is  found  along  the  whole  length  of  the  aorta,  and 

■"'!•!  most  inarketl  ni  the  abdominal  section,  this  secoTid  form  involves 

■'|""i"iii.v  tlie  ascending  aorta  and  transverse  aorta.    Here  we 

'T  patches  ihat  are  of  a  somewhat  translucent  appearance, 


liii 
(.■III-, 


I'- 

•;  i  1 


If     : 


I       I 


wm 


401 


TIIK  CAKDIOVASClLAIi  SYSTEyf 


that  Iwiir  III)  special  reliitioiisliip  to  ciiuTjieiit  vcsmIs,  that  often  have 
their  lonj;  axis  transverse,  ami  very  often  have  a  puckered  ap|)ear- 
anee.  Sclerotic  chanp-s  of  this  nature  are  secondary  to  syj)hilitic 
inesaortitis.  It  is  now  ahnndantly  reco^Mii/ed  that  syphilis  finds  what 
nii);ht  he  descrihed  as  a  "point  of  eh-ction  "  in  the  vasa  \asorinn  of 
more  particularly  the  first  part  of  the  aorta.  There  occurs  a  sinall- 
celled  infiltration  around  tiie  hranches  of  tliese  small  arteries  in  the 
adveiititia  and  media,  and  tliis  is  followed  hy  what  mijjht  almost  he 
descrihed  as  a  "meltiuj;  away"  of  the  media  in  the  afi'ecteil  areas  (see 
Fiji.  2(t.")).  One  of  two  results  may  follow,  either  (and  this  when  the 
I)rocess  a|)parently  is  not  very  acute  or  very  extensive)  the  wiaken- 
inji  of  the  media  is  followed  hy  an  overgrowth  of  the  connective-tissue 
elements  of  hoth  iutima  and  adventitia,  or  (where  the  process  is  more 
extensive  and  more  acute)  in  ])lace  of  such  compensatory  overgrowth 
the  arterial  wall  fiivcs  way,  with  rtsultant  aneurysiu  formation. 


Scrlion  fnmi  !torI;i  of  s\pliiliric  mcsnnrtitis  tn  show  rxtri'inc  (IruciHTjituin  (A  nii-iiia  iitid  iili'iirplii'ii 
tit  I'liistir  ti-^sti*':  /.  thiikinctl  intitiut:  .1/.  liicdiii.  thr  (inrk«\'^t  parts  twiutz  the  I'histir  tissiir.  At  -V, 
this  has  (Ijsapprarcfi ;   -'t    Y.  r(tun<t-ci*llc<i  infiltration. 

{'A)  Monckebergs  Sclerosis.  Mere  ,ve  deal  with  a  i)rocess  in  wiiich 
the  most  marked  feature,  seen  in  arteries  of  larpe  size  sucii  as  tlie 
common  iliacs,  is  an  extensive  de^'eneration  of  the  meilia  with  atnipliy 
of  its  muscular  elements  and  frecpicnt  calcareous  deposits  in  the  atro- 
phied muscle  cells  and.  it  may  l)e.  in  the  elastic  tissue  layers.  A  similar 
I)ro('ess  occnrrinfi  in  the  aorta  lea<ls  to  a  diH'use  dilatation,  with  t'luiiijii- 
tion  and  appearance  of  accessory  curves.  In  the  larfrer  hranches  mIiovc 
noteil  the  de>;eneration  occurs  in  transverse  patches,  so  that  at  aiitupsy 
there  are  to  he  seen  a  succession  of  ring-like  or  transverse  de])rt  --!<>ns 
which  are  very  characteristic  (see  Fij;.  2()S).  The  important  pnint 
regarding;  this  form  is  that  a  similar  calcareous  infiltration  of  tiic  iniiiut 
is  ajH  to  involve  the  smaller  arteries;  if  a  series  of  the  well-kiiown 
"pipe-stem  radials"  he  examined,  it  is  found  that  their  hanlm  -  <>r 


E*i'i'^0^ .^rC^'^A-S'l 


Ain'i:hi(ts(Li:i{(ts/s 


M)n 


Fiii    -MH 


ri)sis  is  not  <liic  ti.  iiitimal  fil)n.sis  l.iit  to  tliis  coiiilitioii  of  incilial 
■ificiitioii  prt'ctdcl  ofu-ii  hy  liypcrtropliy  ,.f  the  imisciilar  ooat.     In 

the  larmier  arteries  it  is  more 
eoniiiioii  to  fin<i  a  eonil)inatioii 
of  nodose  sclerosis  and  this 
media!  defeneration. 

(4)  Endarteritis  Obliterans.  Ail 
the  above  changes,  inelndinji;  the 
syphilitic,  are  found  to  involve 
also  the  arterioles  and  arteries  of 
in.dler  size.  The  syphilitic 
chan^'es  manifest  themselves 
particularly  in  association   with 


^' kiliirit  »  artorii)»(liTOKis  BfleclinK  Ihc  external 

iliiir  arteries. 

Fill.  209 


Tl,.- 

I'lL' 


'in  ..1  ;irliTJ(ile  of  liiyocariiiutn  NliiiwinK  the 
.■ri;r..\vlh  (if  endartenti.'*  uhliternnx. 
!i    rril.iiiic  iMclit  nf    the    arteriole    ai'eil  in 


Fid.  210 


l.onKitiiilinal  «ition  through  a  branch  of 
llie  renal  arter.v.  »ho\vinK  the  relationship  hi- 
twi'cn  weakeninii  ami  atroph.v  of  the  ineiliu  ami 
ailaptive  overRnnvth  of  the  intiina  n.  normal 
or,  inor..  aeiiirately.  Ii.vpertropliiiu  nieilia;  ft,  6, 
areas  of  iIh^  thickened  seleroseil  inlilna  over 
regions  of  iiieilial  ihinninuandcleMneratiou;  at 
r,  the  media  is  <lisorKanized. 


i 


thf  ,. 

iiiiirki 

.il.lii. 
Th. 
In  ,! 
iiiii-i 
rtMiii! 

^iiiiit 
.th,p. 


"  liral  arterioles.     Here  in   the   earlier   stages   there   is  a   weli- 
<l.   perivascular,  small-celled    infiltration,    accompanied    by    an 
'  uh  of  the  intima.  which  may  be  so  extreme  as  to  lead  to 
'ion  of  the  lumen. 

•  '"lose  and  Monckeberg  sclerosis  present  a  succession  of  stages. 

iiiiiller  arteries  either  there  is  a  difl'u.se  hypertrophv  of  the 

'    <'>at,    freciuently   to   be  made  out   in  the  branches  of  the 

rv    (>r   apparently    following   upo,;    this  !in  pcrtrophy,  there 

'"I  there  exhaustion  and  degeneration  of  the  muscle;  there  is 

'-IS  and,  in  addition,  where  the  muscle  has  given  wav,  an 

'\trgrowth  or  sclerosis  of  the  intima,  or  with  difluse  d'ilata- 


toi> 


THE  CMiDlOV ASVri.Mi  SYSTEM 


in 


tidii  of  tlicsc  smaller  iirtt-rics  tlicn-  is  <liH'iis«'.  ratlier  than  nodul.ir,  iiitiiiial 
flii(  kniiiif;;  tlu;  advciititia  nf  the  siiiaHer  arteries  fre(|iieiitly  partakes 
ill  these  ehaiijjes,  l»eeiiiiiiii>,'  fjeiierally  thiekeiie«l  (chronic  periarteritis;. 

A  very  reinarkahh'  I'onii  of  sclerosis  i^  seen  i>i  tlie  uterine  arteries 
and  in  the  hrandies  of  the  ovarian  arteries  of  niultiparie,  clearly  in 
relationship  to  menstruation.  We  have  already  described  this,  show- 
ing how  large  masses  of  elastoid  material  become  formed,  together 
with  the  regeneration  of  a  new  artery  within  the  old  one  (p.  'M)). 
I  fere  again  \vc  deal  with  no  infective  process,  but  with  a  functional 
stimulus,  leading  to  active  new  growth  of  intimal,  medial,  and  adventi- 
tial elements.    The  process  is  clearly  adaptive. 

The  observations  of  Klotz  and  others  show  that  experimentally,  after 
the  intravenous  inoculation  of  certain  bacteria  or  their  toxins,  there 
may  be  developed  localized  areas  t)f  intimal  proliferation.  More  than 
one  ol)server  has  called  attention  to  the  supervention  of  arteriosclerotic 
changes  in  young  adults  following  upon  typhoid  fever.  Were  the 
organisms  of  the  exanthems  and  of  the  commoner  infectious  diseases 
the  cause  of  arteriosclerosis,  we  would  expect  to  find  this  condition 
common  at  or  following  the  period  during  which  these  infections  are 
most  rife,  namely,  in  childhood  and  youth.  On  the  contrary,  arterio- 
sclerosis- is  commonest  in  and  after  middle  age,  at  a  period,  that  is,  wlieii 
the  individual  shows  a  strikin,  -"lativc  immunity  to  infectious  diseases. 

Etiology. — We  thus  supp  rt  view  that  arteriosclerosis  as  such  is 
not  in  general  of  infective  origm  and.  indeed,  is  not  an  inflammatory 
process.  We  hold  that  it  is  the  expression  of  a  disordered  relation- 
ship between  the  internal  pressure  to  which  the  artery  is  subjected 
and  the  strength  of  the  arterial  wall,  that  strength  depending,  in  the 
main,  upon  the  condition  of  the  media.  The  same  results  ensue  when 
there  is  increased  internal  pressure,  the  wall  being  of  normal  strength, 
and  when  there  is  only  normal  internal  pressure,  with  weakening  of 
the  med'ii.  Whether  this  weakening  be  due  to  inflammatory  infiltra- 
tion, as  in  syphilis,  or  to  degeneration,  as  in  old  age,  is  a  seeoiidary 
matter.  The  tendency  will  be  in  any  of  these  conditions  for  the  wall 
to  gi%e  way  at  the  point  of  least  strength;  if  it  give  way  suddenly  an 
aneurysm  is  formed,  and,  what  is  more,  the  intima  is  overstretched 
and  overstrained  and  shows  little  tendency  to  take  on  excessive  growth. 
If  the  strain,  on  the  other  hand,  be  not  excessive,  it  is  followed 
by  active  proliferation  of  the  intimal  connective  tissue  and  this  pro- 
liferation continues  with  the  laying  down  of  layer  upon  layer  until 
the  new  development  is  so  thick  and  firm  that  it  is  no  longer  subjected 
to  strain.    With  this  the  sclerosing  process  becomes  arrested. 

In  favor  of  this  conception  two  series  of  experiments  may  be  quoted: 
(1)  that  of  Klotz,  in  which  holding  up  a  healthy  buck  for  a  few  minutes 
daily  by  the  hind  legs,  over  a  period  of  four  months,  the  increased 
l)ressure  brought  to  bear  upon  the  thoracic  and  cervical  region  led 
to  marke<l  hypertrophy  of  the  heart,  diffuse  dilatation  of  the  thor.icie 
aorta  and  nodose  arteriosclerosis  of  the  carotids,  and  (2)  Carrell  s 
experiment,  repeatedly  confirmed,  of  ligaturing  a  length  of  a  vein  in 


FM..\Ti;  XI 


t  -i 


A  III  11.  i-i  I. -I  ,  i-,i 


i  ..I  .-I  I.I 

.!.■       -.I 

'I      iMi'.ii 


''    "'    ""■     '■•■"■•!    ■lll..|.s     ,1,1     l,,,,.lil.,,M      ,IK.    :,,,.!    -I,,,,,.-. I     l,% 

■"'""■      -l"'^^ll.|      ^ i.\  |..-il|,    |,l,v      ,.1      I ,,|;,,.     ,,.,,^.    I, 

'■""'■"■     "M"-il>"l'i.-.     ■■!     11,,-     ;nl,i,,..     vM,h     in. III,-. I     ,  ,  i.    i  , .. ,~..     ,,. 
-ii'-    li  I'll  I-    {-t..i  11.-.  I    lil.'i,    U  ■ 


I|     1 


fi 


ASKIIiVS.M 


1(17 


ill.'  r..nr>c  nf  till'  lanitid  artery  of  the  rulihit  «.r  cat.  of  ropliuiiij;,  timt 
i  .  .1  iM.rtiuii  of  the  iirtiTV  hy  ii  like  length  of  ii  \Vm.  IVrforinetl  pro|MTly 
ihf  o|)enitioii  Ifiuls  to  no  tliroiiilM)sis  or  arri-st  of  I)1<hm1  current,  anil 
it  tlie  animal  l.e  killed  some  nKmths  later,  the  vein  is  found  .somewliat 
ililated,  hut  showing  a  most  marked  thiekeniu);,  with  laying  d«)wn  of 
lil.r.iiH  tissue  in  all  the  coats,  though  most  markedly  in  the  adventitia. 
Tlii>  fibrosis  can  onlv  lie  regarded  as  fur)ctional  or  reactive,  as  a  resjwnse 
tti  the  increase*!  strain  thrown  upon  the  vein. 

Thns.  to  conclmle,  we  recognize  (1)  a  .-ue  itiManmnitory  endarteritis, 
i\w  to  l.actcria  aiul  their  toxins,  mainly  involving  the  arterioles,  wca- 
-ioriiiliy,  and  to  a  slight  ext.rit.  affecting  the  aorta;  (2)  an  inflammatory 
|M  riarttritis  and  mesaortitis,  of  which  -yphilis  affords  a  most  striking 
t  Aiiinpir;  ('.i)  an  intimal  sclerosis,  non-infiamtnutiry  in  nature,  secondary 
Id  actual  or  relative  weakening  of  the  middh-  coat  (and  there  may  be  an 
adventitial  sclerosis  of  the  same  nature) ;  (4)  aminlial  sclerosis  (Moncke- 
Inrg's  sclerosis)  of  degenerative  nature,  tlie  hardening  being  due  to 
the  deposit  of  calcareous  salts  in  the  middle  coat;  (5)  a  functional 
M  Icr.isis,  as  seen  in  the  arteri.  >  'f  the  uterus  and  ovary  "n  which  the 
nucii.rati(.n  and  i    u   formation  of  the  arterial  coats  v'  the  dis- 

ttiidcl  lumen  of  -  r  older  artery  is  accompanied  by  a  hj.  1^  »r  more 
iuxiirately,  (lasi.iid  deposit  outside  the  newly  formed  artery,  but 
il-  lived  from  the  internal  elastic  lamina  of  the  original  artery. 

Aneurysm.  An  aneurysm  is  an  abnormal  and  circumscribed  dilata- 
ij'n  "I  tile  lumen  of  an  artery.  From  old  time  we  distinguish  between 
'lie  true  aneurysm,  in  which  there  is  i)ersistence  of  one  or  more  of  the 
eoats  of  the  artery  to  form  the  boundary  of  the  dilatation,  and  the  false 
aiieurysin.  in  which  the  wall  of  the  art-ry  in  the  dilatation  has  become 
a  iM.rl.i,!  iind  the  surrounding  tissues  form  a  secondary  wall  enclosing  the 

lolIowingOslcr.  we  may  still  further  classify  the  forms  as  follows: 


l.ln.,.1 


'.'-■I 


True  Aneurysm. 

{(t)  Dilatation  aneurysm:  (l)  fusiform,  limited  to  an  area  of 
one  of  the  larger  \essels;  (2)  cirsoid,  invoKing  an  artery 
of  the  second  order  with  its  branches,  the  whole  series 
thus  l)ecoming  greatly  distended  and  tortuous. 

[0)  Saccular  aneurysm:  this  is  the  commonest  form,  in  which 
there  is  a  localized  and  lateral  giving  way  of  the  aorta  or 
of  a  smaller  artery. 
Dissecting  aneurysm:  here  with  rupture  of  the  inner  coat 
tlie  blood  makes  a  passage,  dissecting  between  the  layers 
of  the  degenerated  middle  coat,  and  either  makes  its 
way  eventually  into  the  pericardial  sac  or  to  the  exterior 
f-f  the  aorta  (leading  thus  to  sudden  death  from  hemor- 
rhage), or  back  again  into  the  artery  at,  it  may  be, 
some  oonsiderahie  distnticc  from  the  original  site.  In  this 
case  the  new  channel  gains  an  endothelium,  and  the 
condition  may  persist  for  years,  the  individual  possessing 
apparently  a  double  aorta,  and  even  double  iliacs,  etc. 


408 


THK  CAimioVASCVLAR  SYSTEM 


[I     ■ 


■Vj 


i  I 


II.  False  Aneurysm  as  altove  desorihed ;  strictly  the  coiulition  here  is 
one  of  heiiiatoina. 

III.  Arteriovenous  Aneurysm  oecurs,  in  whieh,  from  traumatic  or  other 
causes,  there  is  established  a  coniinunication  between  an  artery  and  a 
vein,  either  direct  (aneurysmal  varix),  ii  condition  in  which  there  is 
marked  dilatation  and  tortuosity  of  the  vein  anil  its  branches  receiv- 
ing; the  arterial  blood,  or  indirect,  a  siic  orifjinally  of  the  nature  of  a 
false  aneurysm  intervening  between  the  artery  and  the  vein  (varicose 
aneurysm  . 

1\'.  Other  Forms.  There  are  other  forms  (rare),  such  as  the  parasitic 
aneurysm  seen  in  horses  (in  which  stronjcyloid  worms,  present  m  tiie 
blood  stream  become  arrested  in  oiu'  of  the  smaller  abdominal  arteries 
and,  ftrowinf;  and  setting;  up  irritation  in  the  arterial  wall,  come  thus 
to  fill  a  sac  which  is  in  direct  conununication  with  the  blood  stream); 
traction  aneurysms,  erosion  aneurysms,  etc. 

As  stated  in  the  above  table,  the  conunonest  form  that  we  have  to 
deal  with  is  the  saccular  aneurysm;  next  to  this  the  fusiform  aneurysm 
of  the  aorta.  Hy  far  the  commonest  site  of  the.-e  dilatation.;  is  the 
aorta,  and  in  this  the  ascending  and  transverse  |)ortions.  Aneurysms 
of  the  abdominal  aorta  occur,  but  are  not  so  frequent;  of  the  main 
branches  of  the  aorta  the  i)opIiteal  arteries  deserve  .special  notice, 
although  the  splenic,  renal,  and  other  abdominal  arteries  are  occii  ioii- 
ally  involved.  Another  site,  of  no  small  importance,  is  the  'in  ie  of 
Willis  and  its  branches,  while  carefii!  examination  of  the  sei.nr  brain, 
particularly  in  those  who  iiave  been  syphilitic,  reveals  the  not 
infre(iuent  i)resen<e  of  nniitiple  miliary  aneurysms  upon  the  cerebral 
arterioles.  Similar  aneurysms  soii.etimes  follow  infective  embolism 
in  cases  of  acute  endocarditis.  Both  in  chronic  syphilis  and  in  its 
more  acute  condition  the  infective  process  leads  to  a  weakening  of 
the  walls  of  the  smaller  vessels,  with  conse(HU'nt  giving  way  undtT 
the  blood  pressure.  .\  rarer  form,  the  so-called  mycotic  aneurysm,  is 
occasionally  met  with  in  the  aorta;  here,  ai)i)arently,  bacteria  gaining 
entrance  into  the  vasa  vasorum  lead  to  localized  abscess  formatidii 
in  the  aortic  wall  with  rn])tnre  into  the  lumen.  These,  however,  arc 
comparati\('l\  rare. 

The  coininonest  cause  of  aneurysm  formation  is  syphilis,  and  the 
I  xplanation  of  the  lu-cnliar  fre(|ueney  of  the  condition  in  the  first  portimi 
of  the  aorta  is  n<tt  merely,  as  used  to  be  taught,  because  here  the  wall 
is  sni)jccted  to  the  greatest  internal  pressure  (though  this,  of  course, 
is  a  factor),  but  because  syphilitic  mesaortitis  specially  afiVcts  tins 
region.  The  small-ccllcil  infiltration  around  the  branches  of  the  vasa 
vasorum  is  followed  by  an  extraordinary  destruction  of  the  nitilia, 
the  main  support  of  the  artery,  and  it  is  this  localized  destruction  of 
the  media  tiiat  is  tlie  main  cause  of  aneurysm  formation.  Extreme 
dcgi-neration  of  the  media,  from  non-inflainmatory  causes,  may  have 
the  same  result,  as  may  arterial  trauma  or  erosiim  of  the  outer  mats 
through  progressive  inflammation  i;i  their  neighborhood.    Thus,  where 


CAPILLARIES  AND  VElSS 


409 


iImtc  is  cavitation  in  tin-  lungs  witli  progressivf  .Icstrm-tion  of  tissue, 
It  i>  not  inicommon  to  find  saccular  ancurvsms  of  hranches  of  the 
l.iiliri.mary  artery  projecting  into  the  cavities;  hut  senile,  or  presenile 
(li'LTciuration.  trauma  or  erosion  do  not  compare  in  frequency  with 
~,\|)liilis,  as  causative  agents. 

Results  of  Aneurysm.-  The  aneurysm  heing  due  primarily  to  a  weaken- 
ing: in  the  wall,  the  greater  the  <lilatation,  the  weaker  "becomes  that 
Willi;  there  is  thus  a  tendency  toward  progressive  enlargement.  If  the 
;,Towth  he  not  too  rapid  and  the  enlargement  is  surrounded  bv  .soft, 
iiccununodating  tissues,  there  may  be  a  reactionary  developm'ent  of 
an  adventitial  (ai)siile  arresting  further  growth.  If]  on  the  cc.ntrarv, 
tlK'  sac  impinges  upon  rigid  structures,  by  compres.sion  of  the  nuirient 
\.  >s(Is  ol  those  structures,  instead  of  the  formation  of  such  capsule, 
tlicre  is  a  process  of  necrosis  and  absorption;  the  aneurysmal  wall 
Im' <>in,.s  so  thiiined  as  to  undergo  rupture,  either  with  extensive  hemor- 
rli.i-e  and  sudden  death  or  with  the  formation  of  a  localized  hematoma 
a'id  false  aneurysm.  Thus,  for  example,  a  saccular  aneurysm  of  the 
aMcrHlmg  arch  ma\-  completely  perforate  the  .sternum,  and"  then  form 
a  titlse  aneurysm,  pulsating  and  forming  a  protrusion  in  front  of  the 
Hi.>t,  with  eventual  atn)phy  of  the  skin  that  covers  it,  and  final 
<\t.rnal  rupture.  Kveii  in  a  true  aneurysm,  sudden  increase  of  pressure 
^1^  l.,\  exertion,  may  lead  t.)  rupture  at  some  point  where  the  external 
'  q'sulc  IS  thinnest,  with  resultant  sudden  death. 

On  the  other  hand,  where  the  circulatory  conditions  are  favorable 
w  I.  re.  tor  examph.  the  aneurysm  is  so  situated  that  the  contained 
'l"<«  IS  relatively  stagnant,  a  process  of  obliteration  may  show  itself 
'>  the  laying  d„wii  of  layer  after  layer  of  fibrin  unti'l  the  cavity 
i'"">iHs  hlled  up.  This  complete  obliteration  of  an  aneurv.smal  cavit'y 
I,  li..\vever,  rare.  Xiimerous  attempts  have  been  made' clinically  t'o 
"■I'atc  or  induce  this  natural  process,  as  by  temporary  ocdusio'n  of 
t  M  Mptcry  above  an  aneurysm,  by  the  a<lmiiiistration  of  drugs  lowering 

'  "  '.' •'  PJ-'-^^'Te  and  force  of  the  heart  beat,  and  bv  the  introduction 

"    «in-,  et('.,  into  the  aneurysmal  cavity,  so  as  to  incite  coagulation. 

Progressive  Changes.-In  cases  of  high  blood  pressure  it  is  not 
;  ,"""|"""n  to  hiid  a  marked  hypertrophy  of  the  middle  coats  of  arteries 
I"  'Ins,  „,  recent  years,  Itussell  has  specially  called  attention.     If  the 
1  l'r«;Mir..  be  long  continued  this  is  apt  to  lead  to  degeneration 
Aloncke berg  t\  pe.    Tumors  primary  in  the  arteries  are  <listinctly 

'      N.ine  observers  have  held  that  uterine  myomas  originate,  not 

"til,,  uterine,  but  from  the  arterial  musculature.    This  is  .still  unde- 

■"""■'I.  and  IS  generally  doubted. 


iIm- 


r,ir 


CAPILLARIES   AND  VEINS 

(  apillaries.^-The  disturbances  of  the  cajjillaries  have  not  been  studied 
■  ,   a>  they  deser\  e.    Regressive  changes  are  common  and.  notably 


.*»"  ■!&«•• 


410 


THE  CAHDlOVASCULAR  SYSTE.\f 


1i 


p  i 


under  the  aj;ency  of  hactcrial  toxins,  passive  congestion,  protein  poi- 
sons, varions  mineral  antl  other  drugs,  the  en(h)theliuni  is  apt  to  mani- 
fest a  condition  of  fatty  degeneration,  wliich  in  its  turn  favors  capillary 
hemorrhages.  Hyaline  degeneration  or  infiltration  is  not  uncommon. 
In  our  chapter  on  Inflammation  we  have  called  attention  to  the  pro- 
found changes  that  may  atlect  this  endothelium  as  the  result  of  local 
irritation. 

Congenital  dilatation  of  the  capillaries  (capillary  telangiectasis)  is 
seen  in  certain  nsevi,  and  similar  'Uatation  may  be  acquired  as  a  result 
of  active  or  passive  congestion. 

The  tomors  that  may  originate  from  the  capillaries,  hemangiomas 
and  hemangio-endotbeliomas  have  been  discussed  on  p.  277. 

Veins. — Regarding  the  veins  the  following  may  be  noted:  as  with 
the  capillaries  there  may  be  congenital  or  acquired  dilatation.  Such 
dilatation  nuiy  be  <litt'use  but  more  often  is  sacculated  (varicosity),  with 
a  marked  liability  to  the  formation  of  numerous  anastomosing  vessels, 
w^hich  become  dilated  and  tortuous.  The  acquired  phlebectasis  is  most 
often  the  result  of  passive  congestion,  associated  with  malnutrition,  and 
is  aj)t  to  show  itself  (1)  in  connection  with  vessels,  which,  being  super- 
ficial, lack  the  sui)p(irt  and  resistance  of  surro\niding  tissues  {c.  g., 
hemorrhoids,  veins  of  the  lower  end  of  the  oesophagus  in  portal  cir- 
rhosis), and  (2)  in  the  lower  part  of  tl'"  body,  where  the  weight  of  the 
column  of  blood,  in  addition  to  t'le  poorer  circulation,  favors  the 
dilatation  of  the  vessels  (e.  ij.,  varicose  veins  of  leg,  pelvic  veins,  veins 
of  the  pampiniform  plexus).  Such  varicosity  may  be  accompanied  by 
reactive  thickening  ot  the  walls  (phlebosclerosis),  or,  more  often,  by 
thinning  of  the  same  and  resultant  hemorrhage;  the  condition  of  u^-d- 
nutrition  favors  the  onset  of  inflammation  (phlebitis),  and  of  thrombosis. 

Calcification  may  occur  in  the  venous  wall,  but  it  is  rare. 

Of  inflammations,  there  may  be  acute  suppurative  phlebitis;  this 
is  usually  secondary  to  a  localized  suppurative,  gangrenous  inflam- 
mation, as  appendicitis,  where  with  infective  thrombosis  extending 
along  the  veins  from  the  suppurative  focus,  there  may  be  a  progres- 
sive aseenrling  thrombosis  (^thrombophlebitis),  with  associated  inHain- 
mation  of  the  vein  walls.  Even  in  young  adults  careful  examination 
shows  that  a  thickening  of  the  walls  of  the  veins  of  the  extremities, 
sufficient  to  render  these  veins  easily  palpable,  is  not  uncommon 
{phlebosclerosis),  and  this  without  any  sign  of  inflammatory  or  ti)xic 
disturbance.  We  must  presume  that,  as  in  the  case  of  the  arteries, 
so  lu're,  there  nuiy  be  a  strain  fibrosis. 


THE  LYMPHATIC  VESSELS 

Of  abnormalities  the  most  striking  is  the  condition  of  congenital 
dilatation  of  the  lymphatics  and  localized  areas,  apparently  due  to 
sonr.3  congenital  obstruction  to  the  outflow  of  lymph.    Well-marked 


^flPW^^'i":»!?:W!h:<3IP«^5^-^'" 


THE  LYMPH  NODES 


411 


(•\ii  mplf  s  of  those  conditions  are  macroglossia,  macrocheilia,  hygroma  colli, 
and  "cavernous"  lymphangiomas  of  the  superficial  lymphatics.  Such 
lymphangiectasis  may  also  be  acquired  as  the  result  of  obstruction  to 
the  ixit  of  lymph  from  a  region.  This  may  be  brought  about  by  the 
lyressiire  of  tumors  upon  the  efferent  lymphatics,  or  by  chronic  inflamma- 
tion, mvolving  and  compressing  the  same,  or,  thirdly  by  obstruction 
of  the  lymphatics,  as  a  result  of  cancerous  growth  in  them.  The 
most  marked  and  extensive  state  of  acquired  lymphangiectasis  with 
Its  resultants  is  seen  in  the  condition  of  elephantiasis,  very  common 
ill  the  West  Indies,  and  most  often  the  outcome  of  filariasis.  The 
adult  filarial  worms  make  their  way  into  the  lymphatics,  particularly 
of  the  groin,  set  up  there  a  chronic  inflammation  with  obstruction 
ot  tlie  main  lymphatic  channels.  As  a  result  there  mav  be  a  huge 
eiilarp-ment  of  the  scrotum  or  lower  extremity,  in  which,  in  addition 
to  dilatation  of  the  lymph  channels,  there  is  an  accompanying  diffuse 
fil>rosis  of  the  connective  tissue,  or,  again,  of  the  nerve  sheaths,  and  a 
cutaneous  hypertrophy  (pachydermia).  As  a  result  of  obstruction, 
tliere  may  also  be  rupture  of  the  lymphatics,  which,  when  the  pelvis 
of  the  kidney  is  involved  leads  to  chyluria,  when  the  mest  leric 
lymphatics  are  involved  causes  chylous  ascites,  and  when  the  super- 
ficial cutaneous  lymphatics  undergo  rupture  brings  about  the  condition 
ot  lymphorrhagia. 

\\c  liave  already  discussed  the  tumors  of  the  lymphatics,  namely,  the 
tal>c  tumors  (lymphangiomas),  p.  280,  aiifl  the  true  tumors  (lymphangio- 
endotheliomas), together  with  the  rarer  true  lymphangiomas.  In  this 
'onnection  we  may  recall  that  both  carcinomas,  and,  to  a  loss  extent, 
sarcomas,  are  apt  to  extend  along  the  lymphatics,  and,  doing  this,  may 
'"niplttojy  obliterate  thorn. 


THE  BLOOD  FOBMING  ORGANS 


THE  LYMPH   NODES 


nut 

iii;.'ll 
s.i,'. 

th.  ■ 

\  <  ■ .  *  i 
i'  ;  :i 

AV 

St.fiJ 

ai.t-, 


I'M'  ;.^„M nations  of  lymph  tissue  are  found  liiroughout  the  bo.ly, 

"il,v  III  the  large  groups  anatomically  described  as  cervical,  axillary, 

'iial,  or  other  nodes,  not  only  as  the  tonsils,  and  mixed  with  various 

^ir,\  true  glands  in  the  region  of  the  mouth,  but  also  as  unexpected 

■  ariahle  aggregations  on  the  course  of  lymph  channels  and  around 

'HIS  „i  any  part  of  the  body.    The  amount  of  this  tissue  varies  in 

";'nt  ages  and  some  structures  rich  in  it  in  youth,  as  the  appendix 

'  '  '"I'l^  lose  it  to  a  great  extent  in  old  age.    Its  protective  function 

"ii|«'rtaiit  one. 

normalities.-  A  condition  still  not  understood  is  the  so-called 

lymphaticus  ..f  infancy  and  childhood.    In  this,  accompanying 

'■  iitiN  a  proper  development  of  the  other  tissues,  there  is  found 


412 


THE  cardiovascclah  system 


m 


1:    I 


a  gentTiil  hyperplasia  of  tlu-  lymph  tissues  throughout  the  ho<iy  aiui 
very  t're(|ueiitly  a  jjronouncod  eii!ar>;einent  of  the  thymus.  The  causa- 
tiou  of  this  state  is  most  ohscure,  and  some  hold  it  to  be  congenital. 

Circulatory  Disturbances. — Active  hyperemia  of  nodes  occurs  in  the 
early  sta>;es  of  infections,  and  is  not  so  much  a  step  in  disease  as  a 
preparation  for  function;  the  presence  of  toxins  causes  a  congestion 
of  the  lymph  node  which  results  in  a  i)rolifcration  of  the  lymph  cells 
and  an  increase  in  their  iiumhcr  which  is  defensive  against  the  near-by 
infection.  (Edema  of  lymph  nodes  is  seen  in  the  case  of  nodes  that 
are  inflamed.  Thrombosis  and  embolism  are  of  no  importance,  because 
the  node  has  a  perfect  collateral  circulation  made  not  only  of  vessels, 
but  of  lymph  sinuses,  so  that  its  initrition  can  scarcely  be  interrupted 
by  anything  short  of  a  complete  cessation  of  circulation  to  the  part 
or  member  concerned.  There  is  one  means  whereby  the  circulation 
through  the  node  can  be  interrupted,  viz.,  by  excessive  accumulation 
of  leukocytes  and  lymphocytes  in  the  sinuses  and  the  proliferation  of 
endothelial  cells.  This  is  a  factor  in  producing  the  central  necrosis 
seen  in  the  bubo  and  in  necrosis  of  m  'senteric  and  submucous  nodes 
in  typhoid  fever. 

Varices  are  'lilatations  and  tortuosit.es  brought  about  in  the  sinuses 
of  lymph  iKKjcs,  with  the  final  f«»rniation  of  cysts,  due  to  blocking  of 
the  efferent  'liimncls. 

Inflammation. — Lymphadenitis. — If  bacteria  be  introduced  into  a 
limb  or  into  a  serous  cavity  tliey  are  found  in  the  adjacent  lymph  noiies 
within  a  few  minutes.  At  first  they  nmy  pass  readily  through  these 
and  be  found  in  tiie  blood;  rapidly,  however,  the  node  is  found  to 
become  impervious,  to  become  swollen  and  congested,  to  have  its 
sinuses  filled  with  leukocytes,  and  soon  there  occurs  active  prolifera- 
tion of  the  lymphocytes  of  its  tissue.  Later  the  endothelial  cells  lining 
its  sinuses  become  greatly  ;'.wollen  and  enlarged.  All  these  are  condi- 
tions found  in  simple  lymphadenitis,  but  where  the  pyogenic  microbes 
have  gained  entrance  in  great  numbers,  the  further  phase  of  suppiuative 
lymphadenitis  is  apt  to  sujjcrvene,  the  nodes  becoming  still  furtlier 
swollen,  soft,  and  pinkish  on  sectici!,  yieldiuf  on  scraping  a  th'n, 
purulent  Htiid.  Central  necrosis  may  occur  with  the  formation  of  tliick 
pus.  These  acutelv  enlarged  nodes  are  known  as  buboes.  Frequently 
the  inflammation  affects  also  the  immediately  surrounding  tissue,  wliich 
becomes  congested  and  (edematous  (perilymphadenitis  or  cellulitisl. 

Chronic  lymphadenitis  is  represented  by  the  enlarged  fibrous  nixlts 
which  are  kept  in  a  constant  mild  state  of  inflammation  by  some  irritiitit 
of  moderate  virulence,  such  as  is  seen  in  the  submaxillary  nodes  wUvu 
the  teeth  are  badly  preserved;  e(iually  well-known  examples  are  seen 
in  tuberculosis  and  syphilis,  as  again  in  the  anthracotic  nodes  at  tii<  rnot 
of  the  lung  in  coal  miners,  etc.  The  affected  ncMJes  are  enlarged,  firm, 
and,  according  to  the  nature  of  tlu-  offending  material,  more  •'■'•  \'y^ 
pigmented.  In  the  earlier  stages  there  is  simple  cellular  hypcrplii>ia, 
but  eventually  the  capsule  and  the  stroma  undergo  fibroid  thick*  ning 


THE  LYMPH  NODES 


41 :} 


which  may  be  so  extreme  as  to  cause  atrophy  of  the  lymphoid  elements 
|)r()pcr,  the  node  becoming  represented  by  a  dense  "ncapsuled  mass 
of  fibrous  tissue.  In  addition  to  this  in  tuberculosis,  the  nodes  may 
!)<■  the  seat  of  tubercle  formati«)n,  with  a^Klomeration  and  caseation. 

Regressive  Changes.— Atrophy,— Physiological  atroph>-  of  lymph 
tissue  appears  to  be  pro>;ressive  through  life,  the  lymph'  nodes  being 
at  their  maximum  in  early  childhood  and  diminishing  i)n.gressivelv, 
until  in  old  age  the        ence  of  lymph  tissue  is  most  marked. 

Degenerations  and  Infiltrations.— Hyaline  thickening  of  the  capillary 
walls  and  of  the  stroma  is  not  uncommon  in  coimection  with  chronic 
iiiHammation,  especially  in  tuberculosis.  Amyloid  affection  of  the 
(•ajjillary  walls  is  met  in  general  amyloidosis,  and  more  particularly 
ill  local  amyloidosis  such  as  may  be  found  in  the  head  region.  The 
disease  may  ilso  affect  the  fibrous  interstitial  tissue.  Calcification  is 
III  it  Tuicommon  in  connection  with  old  caseous  tuberculosis,  while  pig- 
mental deposits,  whether  of  dust  particles  or  of  modified  hemoglobin, 
arc  very  frecpient,  t!ie  former  in  the  bronchial  nodes,  the  latter  not 
infrequently  in  the  deeper  mesenteric  and  retroperitoneal  nodes  in 
lascs  of  chronic  intestinal  disturbances  or  where  hemoperitoneum  has 
ixriirrcd.  Tattooing  leads  to  the  presence  in  the  near<"st  lymph  ucmIcs 
iif  the  ])igment  or  pigments  employed.  Necrosis  is  met  most  frequently 
in  tlie  mesenteric  nodes  at  the  ileocecal  angle  in  cases  of  typhoid  fever, 
lint  may  be  encountered  in  various  cases  of  acute  infection,  bacteriemia,' 
(lipiitluTia,  and  bubonic  plague. 

Progressive  Changes.— Hyperplasia.— Hyperplasia,  as  already  indi- 
I  itcil,  is  a  not  uncommon  condition  wherever  a  group  of  lymph  nodes 
I-  -nhjected  to  a  mild  grade  of  irritation;  it  is  peculiarlv  difficult  to 
'Ir.iw  the  line  between  this  functional  hyperplasia  and  iiiflammation, 
il.  in.leed,  it  exists.  The  particular  function  of  these  nodes  is  to  respond 
I"  irritants  by  increased  activity  which  shows  itself  in  lymphocytic 
pri.iit.ratioii.  A  compensatory  hyperplasia  has  been  noted  by  .several 
in v(  -tji^ators  as  following  excisitm  of  the  spleen. 

Hodgkin's  Disease.— In  this  usually  there  is  first  noted  a  progres- 
H\r  tiilargement  of  the  cervical  niules  which  may  become  extreme, 
'"■"inig  huge  conglomerate  masses;  progressively  the  other  lymph 
II"!';  of  the  body  exhibit  enlargement,  group  after  group,  ^iacro- 
>'  irally,  the  condition  differs  from  tumor  formation  in  that,  in  early 
<  !■'  .  tlure  is  a  multiplication  of  different  orders  of  cells,  some  of  them 
I"  -  liraiiiilar  and  eosinophilic,  while  accompanying  this  proliferation 
tl'  I;-  a  coincident  fibrous  hyperplasia  suggesting  strongiv  that  we 
^Mtll  a  clironic  inflammatory  process.  Indeed,  chere  is  one  type 
'iTciiimis  hyperplasia  of  the  lymph  .^les  which  histoh.gickllv 
Its  cl-isely  the  picture  seen  in  Ilodgkii.  ..  disease  proper.  Much 
HUTS  have  demonstrated  the  existence  in  a  certain  number  r.f 
i  lloiigkui  s  disease  of  a  number  of  curious  fine  granules  taking 
•  ■'  tcnstic  stain  and  have  suggested  that  these  are  derived  from 
I'iicilii;  the  granules,  however,  are  not  acid-fast  nor  does  inocu- 


iii 

r( 

.'II. 

<a 

:i  ' 

ti.i 


414 


THE  CARDIOVASCULAR  SYSTEM 


&.    t 


r 


lation  of  material  from  Ilodjjkiii's  disease  into  the  higlily  susrf  ptihle 
piiinea-pig  lead  to  tuherciilosis.  Thus  the  causation  of  the  Jise.:.so 
remains  still  wholly  obscure.  Occasionally,  glandular  enlargements  »i 
the  Hodgkin's-disease  type  exhibit  true  sarcomatous  terminal  chan}^es. 
Lymphatic  Leukemia— As  pointed  out  elsewhere  (p.  240)  we  are 
inclined  to  regard  this  as  primarily  a  hiastomatoid  condition,  a  diffuse 
and  undue  excessive  growth  of  lymphoi<l  tissue  throughout  the  body 
which  eventually  leads  to  the  passage  of  an  excessive  number  of 
lymphocytes  into  the  blood  stream. 

i-iii  I'll 


<^  '&  L 


'^ki,^ 


^.fiiti^,  ^ 


Section  from  a  lymph  Do<le  in  Hodgkin'a 
diseaw,  !<howing  tlic  <liffcrent  order  of  cells. 
II.  degenerating  liukoryte;  6,  fibroblast-  c, 
eopinophile;  d,  lyiiiphocytos,  large  and  small; 
<',  poljnuclears. 


Section  of  liver  from  case  of  leukemia,  shoninn 
the  abundant  leukocytes  of  lymphatic  or  lyiniiho- 
blastic  type  filling  the  sinusoids  or  capillaries:  <i, 
liver  cells  somewhat  atrophied;  6,  sinusoid  or 
capillary  filled  with  lymphocytes;  c,  pigment  in 
endothelial  cells. 


Tumors.— .Such  a  blastomatoi<l  condition  mav  at  times  give  place 
to  malignancy  with  infiltrative  growth  of  the  lymphosarcoraatous 
tissue  through  the  capsule  into  the  surrounding  tissues  (lymphosarco- 
matosis),  or  more  rarely  in  an  individual  lymph  node  there  may  be  a 
primary  and  local  malignant  develoi)ment  (lymphosarcoma  proper). 
But  apart  from  these  true  lympiiosarcomas,  either  small  round-celled 
or  still  more  aberrant,  large  round-celled,  or  spindle-celled  sarcoma- 
tous growths  may  originate  from  the  interstitial  tissue  of  the  nodes, 
or  again  from  the  endothelium  of  the  lymph  and  blood  vessels  (lymph- 
angiosarcoma,  hemangiosarcoma,  and  endothelioma).  In  addition  to 
these  primary  tumors  of  the  lymph  nodes,  it  must  be  emphasi/cd 
that  lymphoid  tissue  is  one  of  the  seats  of  election  for  secondary 
malignant  growths,  and  notably  for  carcinomatous  metastases. 

Hemolymph  Nodes.  -  Attention  was  first  called  by  Heneage  Gibbs,  in 
1884,  to  the  existence  of  small  nodes,  more  particularly  in  the  abdominal 


THE  Sl'LKEN 


415 


area  resembling  in  size  and  distribution  the  ordinary  lymph  nodes,  but 
.lark  in  color  and  differing  in  that  blood  replaces  Ivmph  in  the  sinuses 
These  have  since  been  studied  by  Swale  Vincent,  Wartliin,  and  others; 
they  vary  considerably  in  number  in  different  animals  of  the  same 
siHcies  (including  man),  and  Warthin  and  Meek  have  explained  this  by 
.Icnionstrating  that  the  hemolymph  node  is  capable  of  conversion  into 
the  ordinary  lymph  node.  Their  number  is  increased  in  conditions 
(ailing  for  increased  destruction  of  red  corpuscles,  as  after  splenectomv 


THE   SPLEEN 

The  functions  of  the  spleen  are  somewhat  obscure,  but  it  may  be 
>ai(l  that  it  is  a  "killing  ground"  for  red  corpuscles,  that  it  is  in  fatal 
hie  and  for  a  short  time  subsequently  a  place  of  manufacture  for  the 
saiiie,  and  that  in  case  of  necessity  this  function  may  be  reassumed. 
It  IS  \ery  vascular,  and  its  arteries  open  somewhat  freely  into  its 
sinuses,  at  areas,  the  IMalpighian  corpuscles,  where  the  active  prolifera- 
tion of  lynipliocytes  is  favored  by  this  abundant  supply  of  fresh  arterial 
hl.M.(l.  The  spleen  pulp  consists  of  sinuses  lined  by  endothelium,  in 
whuli  can  be  seen  disintegrating  red  corpuscles.  The  splenic  veins 
form  part  of  the  portal  system,  and  apparently  the  amount  of  relatively 
arterial  blood  that  can  be  temporarily  contained  in  the  organ  is  very 
large.  Its  capsule  is  provided  with  plain  muscular  tissue,  and,  as  shown 
l>,y  Roy,  the  organ  exhibits  a  slow  periodic  contraction  and  expansion 
wli.Tehy  the  contents  of  the  sinuses  are  driven  out  and  renewed. 

Tile  spleen  resembles  the  lymph  nodes  not  onlv  in  its  structure  and 
it^  tiinctioii,  m  short,  is  physiologically  part  of  the  same  system,  but 
like  the  nodes,  it  has  few  diseases  of  its  own.  Like  the  nodes,  it  suffers 
III  general  infections,  and  appears  to  be  to  a  great  extent  protective 

AbnormaUties.— The  spleen  is  rarely  absent,  but  may  be  very  vari- 
'l'l<'  111  sriape  and  size,  and  accessory  spleens  sre  very  common.  They 
arc  iHiuilly  of  .small  size,  and  are  to  be  distinguished  from  hemolymph 
'i;"l<s  tluy  he  oftenest,  but  not  necessarily,  near  the  main  organ 
1  ii  position  of  the  spleen  depends  largely  upon  the  firmness  of  attach- 
'ii'iit  "t  Its  hiliis;  in  splanchnoptosis  the  mobility  of  the  spleen  may  be 
L'r.;i!  aiK  it  lias  been  seen  in  almost  every  possible  position  in"^  the 
IxriioFieiil  eaxity;  if  increase  of  its  size  and  weight  occurs  in  combi- 
■i.ition  with  laxity  of  attachment,  it  tends  toward  or  into  the  pelvis 

Circulatory  Disturbances.-Anemia  of  the  spleen  occurs  as  part  of 


a  ' 
thai 
all.,, 
tii.i, 

SW.'i 

it  ' 
tn. 


'  r.il  aiieniia,  and  by  pressure,  and  is  characterized  bv  a  color  paler 
" mil-  In  atrophic  states,  to  be  spoken  of  later^  this  color  is 
I  'M.iistaiitly  observed.  Active  hyperemia  occurs  in  cases  of  infec- 
■i"!  «t  intoxication,  and  is  scarcely  to  be  distinguished  from  the 
'  ■'  'tate  which  will  be  described  in  inflammation,  of  which,  indeed, 
'  •  eiirly  stage.  Passive  congestion  arises  in  all  obstructions  to 
i  ■"•'1  circulation  such  as  happen  in  cardiac  or  hepatic  disease, 


^ 


\ 


410 


THE  CAHMOVASriLAR  SYSr^.M 


.'2      ' 


hikI  is  clmractfriziMl  hy  ciilarjit-mfnt  of  tlu-  ()rj;iiii,  witli  iiuTcascd  diirk- 
iH'ss  of  color;  iniiTosf()|)ically,  the  >iiiiis(s  arc  ciilart^ftl  an«l  cn^rMrpd 
with  hlooil.  tiuTt'  is  iiim-asril  deposit  of  Mood  |)ij;iiM'iit  :md  tli<  coii- 
neotivf  tissue  of  tin-  traltrcula-  tfiids  to  In-  iiicnasfd;  wiuii  the  .oiuh- 
tiou  of  stasis  hists  for  a  loiij;  time,  tlie  fil)^o>i^  is  fairly  well  marked, 
and  '.lie  cut  surface  of  the  orjrai.  is  perfectly  smooth.  >;listeiu,iK.  dark 
red   >r  hluish  red,  and  the  orpin  is  dense  and  firm-   cyanotic  indtiration. 


Fui    2\i 


Scrtion  frcim  an  onliirRpd  niriijcsti'il  !'f,\rvn  i)f  i-hronic  (.liMlniriivc  1        i  ili.tcnsp,  shoninK  thf  siuws 
gri'aily  ili.-ti'iiclcil:     u.  diluted  splinif  sinus  filli-d  with  n-il  r(,ii     -.  li-s:  h.  splenic-  corpiisili-s 

Embolism,  with  the  formation  of  infarct,  is  frecpient  in  the  s])l(en, 
hy  reason  of  the  larf;e  amount  of  i)luod  that  reaches  it.  although  it  is 
an  orj;an  of  relatively  small  size;  the  embolus  is  derived  usuall.\  from 
the  heart  vaK'es,  and  the  resultant  infarct  is  often  wedjje-shajjed,  with 
the  hase  outward,  of  yellowish-white  or  white  color,  showing  upon  the 
surface  of  the  uncut  spleen  a  raised  area  (Fig.  214);  single  or  iiuiltiplt', 
large  fractions  of  the  total  splenic  hulk  may  he  occupied  hy  infarcts. 
The  infarcted  area  undergoes  coagulation-necrosis,  the  nuclei  hec<di;ing 
hazy  and  indistinct,  while  around  the  aHVcted  area  is  a  hyi)ereniic  zone 
of  reacticai.  As  in  other  organs,  such  an  infarct  may  he  coni|)itt(ly 
ahsorhed  and  its  place  taken  l)y  a  mass  of  scar  tissvie.  In  the  cii-e  of 
septic  embolus  the  infarct  may  break  down  and  abscess  result ;  cvinas 
a  result  of  an  uninfected  superficial  infarct,  there  may  be  fihriiKiiis 
exudate  thrown  out  on  the  surface,  of  which  the  ultimate  roiilt  is 
an  adhesion  to  surrounding  tissues.  This  is  even  more  certain  tw  -'^rwr 
when  the  infarct  is  infected.  Thrombosis  is  much  rarer  than  eiiilx'lism 
but  produces  similar  results.     Hemorrhage  of  the  spleen  may  occur  with 


Tllh:  SI' LEES 


417 


tr.iiitiiii,  l)Ut  tin-  small  licmnrrliajrt's  strn  in  the  lu-morrliani*'  <lisoases 
.in  iiiit  (listiii«iiisliahlf,  mainly  hfcauso  the  >i)lorii  is  itself  fill«'<l  with 
1,1., ml  tliat  is  no  ioiiKt'r  in  the  \rssols;  tlu-  sinuses  normally  contain  so 
iiiiic    Mood  tliat  a  little  more  is  hanlly  to  lie  noticed. 

Inflammation.  Splenitis.  Intlainmation  of  the  spleen  is  s»rn  in  all 
M  \ere  infections  and  into.vications,  and  in  some  of  these,  as  malaria 
;iii.l  typhoid  fever,  its  enlarj;ement  fnrnishes  one  of  the  clinical  signs 
,,t  the  disease.  The  spleen  is  eidarjjed,  and  at  first  firm,  the  swelling  of 
ii~  ( l(inent>  renderiim  the  capsule  tense,  so  that  on  section  the  capsule 
ri|i-  and  the  contents  seem  to  hulg"  .is  if  freed  from  restraint.  The 
c  111  surface  is  seen  to  have  lost  its  distinctness,  ami  the  chocolate- 
(iilored  si)leen  tissue  is  seen  to  Ik'  moist  and  \n\\\>\  in  its  consistence, 
UP  at  times  diffluent.     The  enlargenu-iit  may  at  times  hv  very  great, 

and  .such  i\  spleen   has  lieeii  known 
,..„.  ._,,^  to  rupture,  either   without,  or  with 

^       '  only    slight,    violence.     I'lider    the 

microscope,  the  changes  seen  are 
l)y  no  means  distinctive.  Defi- 
nite necrosis,  es|)ecially  confined  to 
localized  areas,  is  sometimes  seen. 
Suppurative   splenitis   may   occur   in 

Fio    215 


I    I 


>-'tiMli  iMiiii  utiili'  tnfiirf-t  of  splrcii.  It, 
•  ' »ri  1 :  /i.  -iirrountliim  ^plt-fui-  ti^^Mir  wilh 
iM    .-!  1   iimr^tiun  surrcmlHiiiitf  iiit'urct. 


Tul,f'rrnlf»sisnf  >plcrn  wiltl  prcHlurtivc  IuImtcuIous 

pcrispU'nitis  iiiiii  c-iMOduM  tubcrcU'ri,    iMc(iill  Patho- 
IttKical  Mu>t-iilll. 


i!  I    -t.itf   jnst   described,  l)ut  ofteiier  is  merely   the  direct   result  of 

I  '  iiiiiiojiciioiis  infection  in   hacteriemia,  or  of  the  breaking  down  of 

■i  iiiticted  infarct.     \\\  abscess  may  burst  through  the  capsule  and 

i'lMiitc  a  i)eritonitis,  or  if  small,  may  be  absorl)ed,  leaving  a  scar,  or 

'       I'll-  may  remain  and  become  inspissated  and  ultimately  calcified. 

Recurrent  si)lenitis  is  exemplified  by  the  state  of  the  spleen  in  malaria. 

I ,  as  a  result  of  often  repeated  attacks  upon  the  organ  by  the 

n.i  I  organisms,  many  of  which  undoubtedly  ultimately  find  their  way 

M  ^'^a(lnal  enlargement  takes  j)lace.     In  this,  as  well  as  in  other 

•  lironic  aifections,   there   is   hyperplasia  of  the   splenic  tissues 

I  a>  'Veil  as  of  the  interstitial  tis:me,  with  nmch  increase  in  size, 

iiiinness  of  the  tissue  (induration),  and  increased  deposit  of  i)ig- 

-iicli  enlargetnent  constitutes  splenomegaly.    Such  changes  may 


oj^KiK-Pl*    •»*'ik«"«gKBaW«ftSti-Vt«'«"=' 


aatliifaaaBRv  itnAtUgawr  "-,  mm.. 


418 


THE  CMiDIOVASCULAH  SYSTKAf 


J  A. 

mi 

m 

Ii1 1 


occur  in  the  spleen  in  a  nnniher  of  differont  diseases,  malaria,  cirrhosis 
of  the  liver,  syphilis,  kala-azar,  and  especially  in  Banti's  disease. 
Although  there  arc  yet  other  forms  of  disease  in  which  the  spleen  is 
enlarged,  the  histological  examination  of  the  spit  iiic  tissue  is  not  very 
illuminating,  nor  does  it  differentiate  one  form  clearly  from  another. 
None  of  these  forms  of  disease  apjM'ar  to  he,  pro|H>rly  speaking,  diseases 
of  the  spleen,  although  the  spleen  is  always  involved. 

The  franulomu  arc  found  to  affect  the  spleen.  Tuberculosis  appears 
in  miliary  form  in  generalized  miliary  tuberculosis,  and  at  times  one 
finds  agglomerativc  and  caseous  lesiims  (Fig.  21.")).  While  the  syphilitic 
Cnmxna  is  found,  the  disease  is  manifested  oftenost  as  a  general  diffuse 
splenitis,  with  fibrosis.    Leprosy,  Kl&nders,  and  actinomycosis  are  found. 

Begressive  Cluiiges. — Atrophy  of  the  spleen  is  familiar,  as  it  is  seen 
in  the  old.  The  organ  is  small  and  soft,  the  capsule  opaque  and  wrinkled, 
on  section  the  prevailing  color  is  a  pale  red,  and  the  trahcculffi  appear 
to  be  abundant,  not  from  actual  increase,  but  because  relative  loss 
of  the  parenchyma  of  the  organ  brings  the  trabecuk'  close  to  one 
another.    The  weight  of  the  spleen  is  greatly  Icssencfl. 

Degenerations  and  Infiltrations.-  The  spleen  is  a  favorite  site  for  the 
deposit  of  amyloid  in  general  amyloidosis.  The  amyloid  material  ap- 
pears as  translucent  small  areas  of  dark  brown  color,  separated  by 
normal  splenic  tissue;  the  appearance  of  these  amyloid  areas  has  been 
likened  to  that  of  grains  of  sago,  and  the  name  "sago  spleen"  has  been 
given  to  the  organ  thus  affected.  Where  more  advanced  and  dlHiise 
the  walls  of  the  sin>ises  also  are  involved — "baconv"  spleen  (see  also 
p.  39S). 

Pigment  infiltration  is  frecjuent  in  the  sjjleen,  as  will  be  gathered 
from  what  has  already  been  said  about  its  functions  in  the  matter  of 
blood  destruction.  Apart  from  already  mentioned  states,  such  as 
malaria,  in  which  it  is  well  marked,  is  hemochromatosis  in  which  there 
is  a  markcil  deposit  of  pigment  in  various  parts  of  the  body. 

Progressive  Changes. — Hyperplasia. — We  have  considered  in  a  brief 
general  way  the  hyperplastic  states  and  have  also  mentioned,  when 
discussing  leukemia  and  Ilodgkin's  disease,  certain  conditions  in  wliiih 
there  is  an  extraordinary  development  of  splenic  tissue.  In  some  cases 
the  hyperplasia  affects  the  lymphoid  elements,  as  in  lymphatic  leukemia; 
in  others,  as  in  Gaucher 's  type  of  splenomegaly,  the  overgrowth  in- 
volves particularly  the  endothelial  cells  lining  the  splenic  sinuses.' 

Tumord. — Primary  new  growths  are  rare  in  this  organ,  altlioiiKh 
various  connective-tissue  tumors  have  been  reported.  Occasionally 
is  found  a  diffuse  lymphosarcomatous  change,  more  rarely  a  nodular 
sarcomatous  growth.    Secondary'  sarcoma  is  not  common,  though  it  lias 


'  For  the  reason  that  there  is  diffuse  si)Ienic  eiilargenient  in  many  general  >iatcs 
it  may  be  serviceable  here  to  tabulate  nomc  of  the  various  diseases  in  which  splenic 
enlargement,  occurs;  we  give  Ihrni  roughly  in  the  order  of  the  degree  of  enlaruenient 
that  may,  as  an  average,  be  expectetl:  myelogenou.s  leukemia,  malaria  (ague  ciikei, 
splenomegaly  (Banti's),  splenomegaly  (Gaucher's),  lymphosarcomatosis.  Hodgkin  s 
disease  (late  stage),  acute  infections,  clu-onic  congestion,  amyloid,  syphilis. 


-  .  ^  55= 


^^mm^:ff'j^. 


THE  liOSK  MARROW 


419 


1..  <ii  noted  in  cases  of  the  melanotic  variety.    It  is  rcmarkahle  how  rare 
i>  scfoiidary  carcinoma;  i)rinmry  carcinoma  is  (naturally)  unknown. 


THE  BONE  MARROW 

It  is  difficult  to  descrihe  the  hone  marrow  as  a  distinct  tissue;  there 
I.  Ill  It  an  intimate  admixture  of  cells  of  various  orders.  In  man--  re- 
ixrls  it  is  intimately  allied  to  lymphoid  tissue,  not  merelv  in  the  e.xist- 

•  11.  (•  III  Its  meshes  of  ahundiint  lymphocytes.  Imt  also  in  jreneral  structure. 
N.v.rtlicless,  the  existence  of  abundant  leukohlasts  nivinft  origin  to 
^'niMiiiar  leukocytes  (jwlymorphs  and  eosinoi)hiles)  l.riiiKs  it  int<»  a 
ilitl.n  lit  category,  as  do  also  the  ahundant  osteoblasts  and  meKacaryo- 

•  vtcs.  Pathologically  it  is  as  a  bl(.o,|.forming  organ  that  it  possess«s 
interest. 

Circulatory  Disturbances.— Anemia  in  the  body  generalh  is,  for  once. 
a-ociated  not  with  anemia,  but  with  hyperemia  of  this  particular  struc- 
tiirr.  This  IS  most  marked  in  sudden  hemorrhage  and  in  pernicious 
jiiKinia,  the  color  of  the  tissue  being  <lue  not  to  vascular  hyperemia 
Imt  to  the  abundance  of  newborn  and  maturing  ervthrocvtes  in  the 
tivMi.  >i>accs.    The  marrow  in  these  cases  is  markedlv  reddVried 

Inflammation.  It  is  difficult  to  separate  inflammatorv  disturbances 
111  t  ir  I,,,,,,,  marrow  from  inflammation  in  the  bone  as\  whole,  such 
<>tal  .iistiirbance  being  part  and  parcel  of  osteomvelitic  changes  (see 
J)iMas(s  of  l|one).  The  suppurative  and  graimlomatous  forms  will 
Miinl:ir.    he  discussed  m  the  section  upon  bone 

Regressive  Chan«es.-With  advancing  life  the  amount  of  red  marrow 
"ii'l(r  normal  conditions  .shows  progressive  diminution,  the  active 
MMiTovv  n.IIs  of  the  shafts,  and  elsewhere,  becoming  more  and  mor<- 
r.|.la.r.l  by  (at  cells,  until  only  at  the  extremities  (.f  long  bones  is  anv 
n.l  marrow  to  be  detecte.l,  and  with  yet  farther  advance  in  age,  the 
jit  Hing  absorbed,  its  place  within  the  fat  cells  is  taken  bv  a  serous 
'iMi.l  >..  that  It  becomes  translucent  (serous  atrophy).  In  'conditions 
y  osteitis  deformans  along  with  marked  absorption  of  the  trabeculie 
I"  si'ty  inarroxy  may  become  replaced  by  a  fibrillar  connective  tissue 
""I'  "  lis  |y,„K  in  a  somewhat  thick  mucoid  or  hyaline  matrix.  Asso- 
l^lji'-l  with  tins  there  is  a  diminuti(m  •  'le  number  of  osteoblasts. 
11  <  SUM,,  .iiniinution  is  seen  also  in  osteoiudlacia.  ami  in  both  of  these 
"■iinnons  active  red  marrow  is  characteristically  defective 

Aplastic  anemia  .iiffers  from  ordinary  pernicious  anemia  in   that 

>•'    Mm.  there  is  an  absence  of  red  marrow  and  of  signs  of  active 
'•.ituiii  ot  the  erythrocvtes  (p  ,301) 

Progressive  Chan«es.-What  at  nrst  "si.Tht  seems  clearlv  a  hyper- 

i  '.i  ■  I  the  bone  marrow,  viz.,  the  increased  extent  of  red  marrow 


lltTi 

n 
plaFi: 


tr^', 
a  . 


■  ■'•  r>ioo(l  regciicraticn  as  after  hemorrhage,  is  scarcelv  a 
.P'rplasia  in  the  sense  in  which  that  term  is  ordinarily  used 
-  no  uuTcase  in  the  marrow  as  a  whole;  there  is,  nevertheless 
IToduction  of  red  corpuscles  and  coincidently  of  leukocytes 


420 


TiiH  cMi-nnn  \<(  >  i..\i<  sysTK\f 


anil  also  an  awakt  iiin;;  into  activity  .f  (.Hs  liitlu-rto  inactive,  ,(>  tlinf 
wlicrc  prcvitin^lv  then-  liail  >"'ii  t.niy  marrow  \vc  now  encounter  red 
marrow.  In  certain  <'ases  ■•!  in\' 'o^reriotis  leukemia  tliere  may  Ik-  » 
pyoid  marrow  ilne  to  th<  cxct'SM  priMlnction  of  myelohlasts  hikI 
leukocytes. 

Tumors.  'Plic  commonest  form  ■  *'  prinu'ry  tumor  <if  the  hone  marrow 
i>  the  so-cailcil  fiant-celled  svcoma  (p.  .':?7),  a  form  «»f  myeloma  in 
•vliicli  the  nmltiiniileiited  cells  o'  •  'eoih-  ic  type  are  prex-nt  in  >;rcat 
ahimilance  alonjt  with  other,  mi  <'nU<.  cdls  which  ;tre  polynoiiai, 
irregular  in  si/e.  tending  to  he  M'.i  \  ;  inille-sluipetl.  As  we  have 
jMiintcd  nut,  this  ditlVrs  from  ili"  'liC  r<-(mia  in  Ix-inj;  relatively 
henif;n,  so  that  >imple  excision  n  a  in  »l.  ratelx  early  stajtc  i>  rarely 
followed  hy  recurrence  Fibroin  i'  choudro.nM,  and  myxoin;3  of  the 
marrow  have  heen  described,  th^.n^h  rh'V  me  n-fc.  .\n  interesting 
form  of  alveolar  urowtii  often  \v  r  ■  ■::  <i  ilud  as  rimary  carcinnnia. 
hut  apparently  more  truly  of  eDiloUieliomatous  natur''.  lias  heen  report^il 
h\  se\  eral  observers. 


ill    ^ 


l-i.i    -'ir, 


Si'ction  "!  ni.vi'l"ni.i  of  virti'bra        X  I'll" 


uityUoK.) 


Myelomatosis  (myeloma  multiplex  is  aiioth.  r  charac-teristic  furin  of 
hone  tumor.  In  thi>  cnditioii.  ilure  is  the  appeaiancc  in  -f\rral 
hones  simultaii.uu>ly  of  diffuse,  ili  ■icfiiicd  frrowths  of  ^arcon;  ifns 
appearnnce;  the  cells  fomiinir  tlu-se  ^.towt'iis  ^how  Mime  ariifH  ii  in 
different  cases,  perhajis  the  commonest  form  heinj;  ma<l>  tp  ot  m  isses 
of  cells  not  unlike  plasma  cells.  Tresumably  these  are  .'  myeloi  i  .stic 
nature,  rncoinplicateil  <'ases  now  no  metastases,  bi 
an  indi\  iduai  nias>  may  i.ike  «»ri  m.iii^iiiuit  ii;fi!trat:vt- 
when  this  is  the  case,  se<'ondary  LT'.wths  of  saicomato' 
found  in  other  organs.    Occasiona        i li mile- and  roun-!-celk*'  -^sn-inas 


il.v 
j-rti' 


THE  JfiRE'    \LS 


421 


iiiiiv  Im-  eiK-oiuiti'f  «I,  iiriiiiiiatiiiL'  in  tin-  iruirr.  w,  ft     i,.rm(    dcrntd  iicit 
fn  111  marrow  <•(  !|s    irniH-r  but  ir.ini  tlu-  ■  lOiMitivi   ^ssu.  franicwork. 

Wv  iiiiiNt  lioiihi   rh     existj-inf  of  priuiii-y   ran   ikhhh   i>f  tin-  hone 
aii<!.  (Ill  till   (»tli«T  ha  =  ',  niii>t  <m|iha-»izf  thv  jm' iilia'"  li.ihility  of  th 
li.  I'    inurrovN    to  1>.      mv  tl=.'  m  't  of  -.".»idar>    cjiiicitous  irn»\vtli 
T'uii-  <'ureful  oumiii  itii.n  of  t!i.     mul     I     hv  \.   in-r.is  Am.wh  iiifiltru- 
li'in  l>y  ••arciMoiiia  ii«ii\»'(l  ir  !ii     he  i    ,ii     m  m  a  \nrfiv  |>n>[M)rtioti  ol 
ni-is(it    l)rt'u.-,t  caiurr.      (Vri.nn  ni('tt>{iia!it    tinman    show    a   jH-culiar 
l!:il  iht.\   to  form  motustns«-s  in  {he  Im>ii.    marrow,  notahl.N    'arnnomas 
1.1  i'      thyroid  aiui  pn    tati-,  ar»<l  hyix-n,  phr  mas. 


THE 


ENAl,?' 


It  i--  (lifti    ilt  to  pla<f  i 
iii'id  to  the  .  t>rtex  'f  the 
iiniially  we  can   find  m;  vl 
i^  derived   fro;-;   the   ^^     ijk. 
iippareiitly  dep.i  'ed  '\ 

priiiMTty  with  wl   ■  h 
foinicctioii  with         Miten   ■ 
tVatrn-  a  rrii.ari     '■■■  e  iiif' 
ha  r  .Ictert  4iu'd       .-onsi-rri 

Til     idn  '  'I  is  a  di-ctl -ss  < 


It' 


tl 


V  adrcilii 
idney  a 
■  relatiui,  ! 
•tie  -xst'iii, 


ryoffetii  tieally 
m,  1»      fune- 


It^ 


>m  I  ■ 
•  an 
rrtioi 
u    ■ 
all 


didia 

have 

•  t  i  ve 

t.s  ill 

rikin^ 


CI.I' 

ti„ 
til. 

Cfi 

i>  • 

r|„ 
t;U' 


'!., 


|)oi.'  ,       ',,.  iii,i   ,.y^  almiul 
\  and  a  nj«"«hi!l  I      The  foriii< 
iiiteniiost  coiisi        of  uia--t 
^on*  jlomeniUjM,      ,'  w'uh 
'ntaiunj;     hiindant 
file  eoiiiiiiii>.  of  cell- 
ie  11]"    'f  irre^rtdar  iii 
na  reticularis     The  li.rii,  ..u. 


■;t':iii 


ii, 


'Ui 


ecli 
tli< 

■en  i 


t- 


.  the  V 

I!  l)etwe<' 


le  I 
'IS  fiK  he  on 

^H'        ii  It  IS  endow 

.  tl         IS  a^  its  most 

:<•  arterial  tonus;  wherefore  we 

ith  the  vascular  system. 

,      ,'  in  clo.se  juxtaposition  to  the 

tly   vaseulii'-,  and  coiisistinj;  of  a 

divided  into  three  zojh's  of  wliich 

cells  with  relatively  large  nuclei, 

consists  of  coluniiis  of  polygonal 

jioi        the  cajnllarics  running  be- 

ona  L     iculata;  the  innermost  layer 

i  I'olyi    (Iral  cells,  often  i)igmente«l, 

o!  cut  rely  diH'erent  structure,  con- 

with    1   imerous  nerve  fibrils,   being,   in   fact, 

iglia  .     the  sympathetic  system. 

iiserve,  obscurely,  it  is  true,  a  certain  inter- 

fiinctioi  a!  activity  of  the  adreii'd   the  thyroid, 


Abnormalities 

'■'  '  la\C( 


Herat    e  system.    Further,  th  r  ■  ;s  evidently 
le  a.innal  glanils  and  the  pigments  of  the 


Hypopi  the  adrenals   is   found   at  times  in 

iiliires  ot  iopment  of  brain  tissue,  and  in  some 

sexual  dexelopment.     Horseshoe  adrenals  have  been 

accessory    adrenals    are   common;    these    appear   as    tiny 

'dies  oi:  the  surface  of  the  otherwise  normal  adrenal;  at 

ory  adreiiai  ii,-,Mie  niay  be  found  underneath  the  kidney 

embedded  in  the  liver  substance,  or  again  in  the  neighbor- 

<•  testis  and  in  the  broa  !  ligament. 


422 


THE  CARDIOVASCULAR  SYSTEM 


m  '' 


lit 


u  1 


Circulatory  Disturbances. — Anemia  is  unimportant;  hyperemia  of 
the  active  sort  occurs  in  infective  diseases,  and  passive  hyperemia 
in  general  states  of  blood  stasis;  with  hyperemia,  hemonhage  is  prone 
to  occur,  usually  punctate,  hut  sometimes  of  large  size  (venous  infarct). 
Fairly  frequently  in  our  autopsies  on  infants,  we  have  found  hemor- 
rhage in  one  or  other  adrenal  without  having  any  clinical  details  to 
correlate  with  the  condition,  and  in  quite  a  proportion  of  cases  in 
young  children  hemorrhage  or  infarct  of  one  or  both  adrenals  has  been 
the  only  serious  lesion  seen  to  explain  sudden  death.  It  seems  as  if 
there  were  at  times  symptoms  referable  to  suddenly  occurring  hemor- 
rhage of  the  adrenal,  viz.,  a  sudden  onset  of  abdominal  pain,  vomiting, 
diarrhoea,  and  collapse. 

Inflammation. — Acute  inflammation  of  the  adrenal  occurs  in  some 
cases  of  pyemia  and  by  extension  of  inflammation  from  nearby  struc- 
tures. It  seems  likely  that  cavitation  of  the  adrenal  is  often  due  to 
roughness  in  removal  of  the  organ.  Softening  may,  however,  occur. 
Abscesses  may  appear  at  times,  and  sometimes  a  considerable  degree 
of  fibroras  is  found. 

Infective  Qranuloma.^ — Tuberculosis  is  important  by  reason  of  its 
relation  to  Addison's  disease.  The  adrenal  may  be  affected  by  miliary 
tubercles,  but  more  often  by  massive  tuberculosis  with  caseation, 
affecting  one  or  both  organs;  here  a  marked  degree  of  fibrosis  is  at 
times  to  be  seen.  Syphilis  has  been  noted  in  a  few  instances,  usually 
as  gumma,  though  there  are  enormous  numbers  of  spirochetes  in  the 
adrenals  of  the  premature  congenital  syphilitic. 

Begressive  Changes.— Atrophy  occurs  in  the  old,  but  the  alterations 
in  size  appear  to  be  usually  connected  with  differences  in  the  amount 
of  fats  and  lipoids.  It  may  be  said  that  no  organ  in  the  body  varies 
so  little  in  size  from  earliest  to  latest  life.  Degeneration  of  cloudy  and 
of  fatty  nature  is  seen  in  states  of  general  toxemia.  Amyloid  disease 
is  found  in  generalized  amyloidosis  and  necrosis  is  seen  in  intoxication 
and  locally  in  infarcts  from  thrombosis. 

Progressive  Changes. — Hyperplasia  of  one  organ  may  occur  in  cases 
of  insufficiency  of  the  other,  and  it  has  been  noted  that  in  destructive 
disease  of  the  adrenals  there  may  occur  a  multiplication  of  chromaffin 
tissue  outside  the  adrenal,  especially  in  the  solar  plexus.  There  is  still 
some  debate  as  to  whether  in  chronic  Brigiit's  there  be  not  a  distinct 
hypertrophy,  more  particularly  of  the  cortex  of  the  adrenals. 

Tumors.— Two  wholly  different  orders  of  tumors  originate  from  the 
medulla  and  cortex  respectively.  Several  cases  are  on  record  of  pritiiary 
new  growths  of  the  medulla  which,  carefully  studied,  are  seen  to  be 
true  neuromas  or  neurocjrtomas,  resembling  in  cell  arrangement  and  in 
the  size  and  appearance  of  cells  the  developing  sympathetic  ganglion 
(p.  245).  In  the  cortex  we  obtain  tumors  of  a  wholly  different  order. 
The  simplest  and  most  benign  present  themselves  as  nodules  from  the 
size  of  a  pea  or  less  upward,  originating  within  the  cortex  and  in  struc- 
ture, formed  of  columns  or  cell  collections  recalling  the  arrangement 
of  the  zona  fasciculata.    These  may  be  spoken  of  as  adrenal  adenomas. 


THE  THYROID  GLASD 


423 


Several  cases  are  now  on  record  of  an  intermediate  type  presenting 
transition  from  the  above  arrangement  to  a  sarcomatous,  diffuse, 
and  infiltrating  distribution  of  the  tumor  cells.  In  other  tumors, 
asain,  the  capillaries  or  sinusoids  of  the  new  growth  become  a  striking 
feature  and  the  general  arrangement  is  difficult  to  distinguish  from 
that  of  the  hemangio-endothelioma.  Lastly,  there  may  be  what  seem 
to  he  pure  oval-  or  round-celled  sarcomas.  As  we  have  pointed  out 
elsewhere,  we  believe  that  these  are  all  stages  or  states  of  development 
(if  one  common  form  of  tumor,  •  j  mesothelioma  or,  if  the  term  be 
I)ret'erred,  the  hypernephroma  proper.  Great  confusion  has  hitherto 
reijiiietl  regarding  the  nomenclature  of  these  tumors.  They  have  been 
•,|)tikeu  of  as  carcinoma,  as  carcinoma  sarcomatodes,  as  endothe- 
liomas, etc. 

Secondary  carcinoma  is  l)y  no  means  uncommon,  particularly  in 
cases  of  cancer  of  tiie  pancreas  and  stomach.  More  rarely  do  we  en- 
eouiiter  secondary  sarcomatous  growths  in  the  adrenals.  Blood  cysts 
ha\c  heen  reported  after  hemorrhage,  and  lymphangiectases  occasionally 

(iirnr  in  the  organ. 


THE   Tir."^OID   GLAND 

The  thyroids  are  developments  from  the  loor  of  the  embryonic 
iiKiiitli.  .\t  a  very  early  period  the  connection  between  the  alimentary 
I  iiiial  and  these  offshoots  from  the  same  becomes  broken  and  the  gland 
«le\(lo[)s  through  further  growths  of  side  processes  which  in  time 
hcconie  dissociated  into  a  collection  of  ductless  vesicles.  Even  late 
111  htV  we  occasionally  encounter  in  the  stroma  of  the  organ  small 
nill((  tions  of  cells  tending  to  develop  into  new  vesicles.  Each  vesicle 
prcHiits  normally  a  single  lining  layer  of  cubical  epithelium  and  is 
Mirrontided  by  a  connective-tissue  stroma  rich  in  bloodvessels  and  lym- 
[Hiat us.  .\i)parently  under  normal  conditions  there  may  be  considerable 
variiition  in  the  contents  of  the  vesicles,  which  show  all  degrees  of 
">!lH^teIl(■y  up  to  a  dense,  inspissated,  gluey  or  colloid  material.  Upon 
<  Mr.njtioii  this  colloid  material  affords  iodothyrin,  which  appears  to  be 
til'  ^iMcihe  i)roduct  of  the  activity  of  this  gland. 

AbnormaUties.— There  may  be  marketi  variation  in  the  size  and 
r.l.tioij.hip  of  the  middle  lobe,  and  in  a  considerable  proportion  of 
'1-'-  tins  shows  a  remnant  of  the  original  median  duct  in  the  form 
"I  I  process  of  thyroid  tissue  passing  upward  toward  the  middle  of 
t  !'•  h.void  iKHie,  the  processus  pyraviidalis,  sometimes  adherent  to  this 
]'}  ■•  •aiid-like  contmuation  of  connective  tissue.  In  rarer  cases  there 
'iireet  extension  of  this  co  the  foramen  rcecum  of  the  tongue,  or 
!'r«  M  lice  of  a  fistula  leading  down  from  the  foramen  ctecum  in  the 
'  '■  line  toward  the  gland.  Again,  at  puberty  or  even  later,  cvsts 
'"nil  u!  tlie  substance  of  the  tongue  or  between  this  and  the  middle 
i|<>se  are  lined  by  glands'lar  epithelium  and  are  evidently  rem- 
"I  the  original  thyroglossal  duct  which  have  now  taken  on  active 
""".    Accessory  lobes  or  isolated  masses  of  thyroid  tissue  are  not 


t!i. 

III!. 

II' 

Inl,, 

.Sic: 


424 


THE  CARDlOVASCiLAR  SYSTEM 


uiicoinmoii.  When  these  occur  between  the  trsophagus  suul  trachea 
they  may  cause  grave  dyspiuea  tlirough  further  eiihirgemeut  and  con- 
gestion. A  remarkable  feature  is  that  occasionally  collections  of  typical 
thyroid  tissue  have  been  found  included  in  one  or  other  part  of  the  bony 
skeleton,  and  this  without  any  obvious  tumor  of  the  thyroid.  They 
appear  to  be  fcetal  inclusions.  Cases  of  congenital  hypoplasia  or  even 
of  complete  absence  are  on  record  as  well  as  others  of  congenital  hyper- 
plasia. These  conditions  of  imperfect  function  result  in  delayed  growth 
of  the  individual  and  the  state  of  cretinism. 

Circulatory  Disturbances.—  It  has  been  observed  that  with  menstrua- 
tion and  pregnancy,  the  thyroid  shows  a  sympathetic  congestion  in  the 
female  and  the  great  vascularity  of  the  organ  makes  it  susceptible  to 
hypereniic  states,  so  that  in  passive  congestion  it  may  be  found  markedly 
enlarged.  Cysts  of  hemorrhagic  origin  are  common  in  the  organ,  but 
this  apparently  always  in  association  with  the  formation  of  local 
"adenomatous"  growths. 

Inflainination. — It  is  somewhat  striking  that  in  so  vascular  and 
so  exposed  an  organ  acute  inflammatory  changes  are  rarely  noticeal)!e. 
Abscesses  occasionally  occur  in  cases  of  pyemia,  and  have  cxen  been 
known  in  pneumonia  and  typhoid  fever. 

Regressive  Changes. — The  thyroid  (,."  elderly  indiviiluals  not  infre- 
quently shows  extensive  atrophy  of  the  parenchymatous  elements 
accompanied  with  generalized  fibrosis,  with  hyaline  degeneration,  and  at 
times  with  calcareous  deposits.  In  long-continued  cases  of  exophtliiilniic 
goitre  we  obtain  cvideiice  that  the  parenchymatous  cells  undergo 
degeneration,  possibly  from  overwork.  There  .ire  cases  on  record  in 
which  the  synptoms  of  hypersecretion  have  been  followed  by  tlitise 
of  inadecjuate  secretion  or  hypothyroidism,  this  being  correlated  with 
a  form  of  atrophic  flattening  of  the  cells. 

Progressiye  Changes.  -The  progressive  changes  of  the  thyroid  are 
difficult  to  classify,  but  the  work  of  recent  years  appears  to  be  throwing 
increased  light  upo  the  relationship  between  the  different  forms. 
There  may  be,  in  the  first  place,  a  condition  of  active  hyperplasia  of 
the  gland  associatetl  with  increased  fimction  and  coincident  increased 
formation  of  the  specific  internal  secret- )n.  This  is  notable  in  the 
enlarged  s(»ft  gland  of  early  acute  cases  of  Graves'  disease.  In  these 
cases,  the  alveolar  epithelium  is  j)rominent,  the  cells  of  good  size,  and 
there  is  evidence  of  active  i)roliferation  of  the  same  in  the  form  of 
ridges  and  papilhe  projecting  into  the  vesicles.  There  may  even  l)e 
more  than  one  layer  of  epithelial  cells,  and  many  mitotic  figures.  Xv- 
companying  this,  the  organ  is  distinctly  vascular  and  the  alveoli  are 
moderately  distended  by  a  thin  secretion.  The  picture  is  identiutl 
with  that  seen  in  active  regeneration  of  the  gland  following  experi- 
mental removal  of  part  of  it.  An<»ther  group  of  cases  exhibits  a  ditiise 
enlargement  of  the  vesicles  (diffuse  parenchjrmatous  goitre)  but  now  tlie 
epithelium  is  of  a  flatter  type  and  the  vesicles  are  distended  with  <li  iist 
colloid;  the  cut  surface  is  gelatinous  an<l  there  is  no  markedly  iii'  n-;;  td 


1  i 


THE  THYROID  GLAND 


425 


vascularity.  This  condition  may  represent  a  late  stage  of  exophthalmic 
piitre  with  marked  amelioration  of  symptoms  or,  on  the  other  hand, 
may  develop  insidiously,  with  marked  diffuse  enlargement  of  the  gland. 
Tile  very  denseness  of  the  colloid  and  the  absence  of  vascularity  indi- 
cates that  in  these  cases  there  is  accumulation,  in  place  of  increased 
(lixharge,  of  the  internal  secretion.  Indeed,  up  to  a  certain  ix)int, 
>ii(li  cases  may  sliow  very  little  beyond  the  local  effects  of  the  thyroid 
enlargement  and  little  general  disturbance  save  when,  through  handling 
IIP  operation,  active  congestion  is  induced  ami  the  grave  sympt  mis  of 
li.\  |)crthyroidism  may  supervene.  If  the  condition  progress  still  farther, 
with  pressure  atrophy  of  the  epithelium  and  loss  of  function,  symptoms 
III  myxo'dema  may  show  themselves.  In  yet  another  series  of  cases 
wr  (leal  not  with  geneialized  but  with  nodular  localized  hyperplasia  of 
till'  thyroid  tissue.  These  are  usually  spoken  of  as  adenomas,  a  term 
whose  applicability  we  doubt.  They  present  not  so  much  active 
ny.r^Towth  as  a  distension  of  the  individual  vesicles  with  colloid. 
^ Vt  ill  some  cases  there  is  evidence  of  true  adenomatous  development. 
We  may  thus  encounter  the  foetal  adenoma,  so-called  because  in  this 
(oiHlitioii  we  find  areas  formed  of  clusters  of  cells  situated  in  the  stroma, 
rcMinbliiig  closely  the  cell  clusters  seen  in  the  embryonic  thyroid! 
Till X'  evidently  are  undergoing  active  proliferation,  an(i  what  vesicles 
an  present  among  these  are  of  small  type  and  lined  by  small,  roundetl 
iir  (iibical  cells.  This  form  .iceording  to  Wolfler,  jiresents  itself  as 
iiiiiltipic  well-defined  nodes,  originating  apparently  from  mother  tissue 
wliM  li  has  remained  latcrit  between  the  previously  developed  follicles. 
111.  >u-(alled  sulenomas  in  their  early  stages  are  very  vascular  and 
liiiliii'  to  extensive  »"-morrhages  in  their  substance,  which  result  in  the 
Inniiation  of  cysts,  .metimes  of  great  size.  Yet  another  form  has 
Ihi  II  railed  by  \irchow  the  struma  vasculosa.  This  is  not  a  blastoma 
|'rii|ii  r  but  merely  a  great  dilatation  of  the  superior  and  inferior  thyroid 
:irti  rits  and  their  branches,  leading  sometimes  to  great  enlargement 
organ  with  pulsation  and  the  development  of  bruits  audible 
stethoscope.  This  condition  is  often  accompanied  by  indica- 
1^  I't'  hyperthyroidism. 
Tumors  Proper.-  The  proliferative  conditions  just  mentioned  may  give 
pliir,  I,,  true  adenocarcinoma,  or  tiiis  may  (>riginate  without  previous 
r  al)|(.  goitre.  Arising  thus  the  condition  is  markedly  malignant, 
iAt(iisi\e  infiltration  of  the  surrounding  tissues,  penetration  of  the 
'I  and  of  the  :<  :-  ,/"  the  neck,  accompanied  by  rapid  increase 
'  i/e  of  the  org.  •'  i!  ;  the  formation  of  metastases  in  the  lungs, 
'  'I .  Loeb  and  .  •  >  .s  have  described  both  in  man  and  the  lower 
'^  a  true  carcinoma  sarcomatodes,  namely,  a  combination  of  the 
lit  growth  of  the  parenchyma  with  coincident  sarcomatous 
rpjidsis  ()f  the  interstitial  tissue.  Secondary  invasion  of  the 
'iv  nuiligmint  growths  originating  in  other  tissues  is  compara- 
rr;  occasionally  there  may  be  direct  extension  into  the  gland 
r>  of  the  trachea  and  trsophagus. 


Ot     ill! 

liy  till 
tiiih-,  I 


iiii^, 
with 
tnii  I 
ill  tl 

lll;||. 
illlill 

Ili;ih 

lint, 
III-. 

ti\, 
lu  • 


c  I 


426 


THE  CARDIOVASrrr.AR  SYSTEM 


THE   PABATHTROIDS 


R '  I 


We  owe  particularly  to  Sandstrom  (1880),  Gley  (1891),  Cristiani 
(1892),  and  Cohn  (lS!*ro  the  recognition  of  the  parathyroid  glands, 
and  from  the  stage  m  wliioh  these  little  bodies  were  regarded  as  unde- 
veloped and  latent  masses  of  thyroid  tissue,  we  have  passed  to  perhaps 
too  great  a  belief  in  the  importance  of  their  function.  They  are  usually 
four  in  number,  situated  either  immediately  outside  or  imbedded  within 
the  thyroid  tissue  in  the  region  of  the  posterior  inner  edges  of  the  lateral 
lobes  above  and  below,  and,  in  their  histological  structure,  resemble 
the  embryonic  thyroid  tissue,  with  frequent  cjst-like  spaces.  Embryo- 
logically  it  is  found  that  they  have  a  separate  origin,  being  derived  as 
outgrowths  of  the  epithelium  of  the  third  and  fourth  branchial  clefts, 
close  to,  but  distinct  from,  the  points  of  origin  of  the  lateral  thyroid 
masses.  They  are  0  to  8  mm.  long  by  3  mm.  in  breadth.  From  their  simi- 
larity to  undeveloped  thyroid  tissue,  it  is  difficult  to  state  with  precision 
whether  certain  small  masses  found  in  th.:  tissues  of  the  neck  between 
the  thyroid  and  the  arch  of  the  aorta  are  accessory  thyroids  or  accessory 
parathj  roids.  Tliese  are  so  common  as  to  make  the  frequent  state- 
ments of  surgeons  that  they  have  removed  both  thyroids  and  para- 
thyroids without  obvious  results  of  little  value. 

The  obser\'ations  of  MacCallum  suggest  the  existence  of  a  poison 
in  animals  whose  parathyroids  have  been  removed,  which  enters  into 
combination  with  certain  cells  of  the  nervous  system,  so  that  there 
develop  *he  symptoms  of  t-t'Uiy,  a  condition  characterized  by  spasmodic 
contractions  of  the  muscles,  con\ulsions,  rapid  respiration,  with 
dyspnoea  and  salivation,  followed  by  coma  and  death.  Accompanying 
this  there  is  increased  excretion  of  calcium  salts  with  diminution  of 
the  calcium  contents  of  the  blood  (MacCallum  and  Voegtlein),  while,  as 
pointed  out  by  Erdheini,  the  extirpation  of  the  glands  in  the  rat  is 
followed  by  defective  deposition  of  lime  in  the  large  incisor  teeth, 
followed  by  brittleness  and  a  tendency  to  breaking.  Fracture  of  the 
bones  of  these  animals  is  followed  by  delayed  conversion  of  the  cartilagi- 
nous into  bony  callus,  affording  a  picture  that  recalls  somewhat  that 
seen  in  rickets.  If  an  animal  showing  these  symptoms  be  bled,  they 
are  checked  and  can  be  made  to  disappear  by  the  injection  of  emulsions 
of  parathyroid.  This  condition  of  tetany  in  humankind  occurs  most 
often  in  infants  and  here  se\'eral  observers  have  noted  the  existence 
of  hemorrhages  in  the  parathyroids;  these,  however,  are  not  present 
constantly  and  a  further  condition  of  gastric  tetany  is  described  asso- 
ciated with  dilated  stomach,  etc.,  in  which  no  lesions  have  been  made 
out  in  these  glandules.  An  attempt  has  lately  been  made  to  correlate 
hemorrhagic  and  necrotic  changes  in  the  parathyroids  with  marasmus 
of  infants. 

Hyperplasias,   or  so-called  benign  adenomas,  have  been  described, 
without  much  evidence  of  functional  disturbance. 


Mim-^ 


mwi'MP-j^ry, 


■■jr'^^&&m. 


CHAPTER    VII 

THE  RESPIRATORY  SYSTEM 
GENERAL  CONSIDEBATIONS 


The  chief  function  of  the  respiratory  system  is  the  intake  of  oxygen 
and  the  discharge  of  carbon  dioxide  for  the  benefit  of  the  economy  at 
large.  This  is  accomplished  by  the  filling  of  the  air  sacs  with  air  on 
the  one  hand,  and  the  capillaries  and  lymph  spaces  with  blood  and 
lymph,  on  the  other,  and  the  free  interchange  of  the  gases  between  the 
two,  separated  as  they  are  from  one  another  by  the  alveolar  epithelium, 
the  capillary  or  lymphatic  wall,  and  what  connective  tissue  may  chance 
to  intervene.  It  has  been  calculated  that  there  are  725,000,000  alveoli 
in  the  lungs,  exposing  a  surface  of  roughly  210  square  yards,  so  that 
the  air  cells  are  lying  close  to  a  film  of  blood  that  has  been  estimated 
to  be  10/x  in  thickness.  The  amount  of  gaseous  interchange  can  be  thus 
seen  to  be  enormous,  yet  this  is  but  a  mall  part  of  the  process  of  oxy- 
genation of  the  tissues,  for  only  a  small  amount  of  oxygen  undergoes 
re(luctif)n  in  the  corpuscles.  The  cells  have  an  intense  avidity  for 
oxygen,  and  are  capable  of  storing  it  to  some  extent,  for  the  tissues  have 
lieen  shown  to  bo  capable  of  metabolism  for  some  time  in  an  oxygen- 
free  atmosphere  or  when  transfused  with  oxygen-free  saline,  during 
\\ hiih  metabolism  carbon  dioxide  is  abundantly  discharged.  The  arterial 
lil(»o(l  is  almost  but  not  quite  saturated  with  oxygen,  and  even  in 
a-pliyxia  some  oxygen  can  still  be  obtained  from  the  blood.  Of  the 
lirocess  of  diffusion  which  the  oxygen  imdergoes  from  the  time  it  leaves 
the  ctjrpuscle  until  it  joins  and  becomes  part  of  the  biophoric  molecule 
\\(  know  very  little,  but  we  suppose  the  transference  to  be  fairly  direct. 

Anatomically,  it  may  be  noted  that  there  are  abundant  elastic  fibres 
III  tlie  aheolar  walls  which  assist  in  the  recoil  of  the  lung,  in  the  ex- 
iMiMun  of  air,  and  in  the  circulation  of  the  blood  and  lymph  in  the 
alyrolar  walls;  that  the  right  bronchus  is  larger  than  the  left  by  one- 
iliinl,  and  that  the  bronchial  tract  has  a  capacity  that  is  one-thirtieth 
t!i:it  (if  the  lungs;  that  the  varying  diameters  of  the  larynx  and  trachea 
a IV  ( \ idintly  to  impart  a  rotary  motion  to  the  current  of  inspired  air; 
fiii'l  that  a  double  blood  supply  from  the  right  ventricle  through  the 
I'lil'ii.inary  artery  and  from  the  aorta  through  the  bronchial  artery  give 
a  .   ;  V  free  collateral  circulation  in  all  parts  of  the  lung. 

The  Air  Passages.— This  term  includes  the  entire  tract  from  the 
i  -  ii-  In  the  terminal  bronchioles,  a  considerable  dbtance;  the  effect 
"li"  the  insjHred  air  is  that  it  enters  the  air  sacs  (1)  at  the  body  tem- 
1  r,;iii,.,  (2)  impregnated  if  not  saturated  with  moisture,  and  (3) 


,.  ^bV^Br  . 


428 


THE  liESriRATORY  SYSTEM 


\  i 
i 


It:      I 

I!    i 


(It-void  (iiorinully)  of  du.st  and  fort'i);ii  particles,  and  tlu-rofore  sterile. 
The  nasal  passajjes  have  an  important  effect  in  l)rinj;inji  this  state  of 
artairs  about,  and  the  large  surfaces  of  the  turbinated  bones  war  i  and 
moisten  the  air,  and  their  moist  surfaces,  like  those  of  the  whole  tract, 
entangle  particles  to  an  enormous  extent.  If  the  effect  of  this  mech- 
anism be  nullified  by  mouth  breathing,  it  will  be  seen  at  once  how  serious 
may  be  the  effects  pnKluced  upoi  *ht  lower  parts  of  the  tract.  Mouth- 
breathing  may  result  from  nasal  obstruction  of  many  different  sorts- 
from  congenital  or  ac(|uired  narrowness  of  the  passages,  from  trauma, 
from  the  secretions  of  iuHammation  or  the  thickening  resulting  there- 
from, from  tumors,  especially  polyps,  and  from  lymphoid  enlargements. 
Of  the  last,  adenoid  growths  of  the  nasopharynx  are  very  common  and 
very  important;  occurring  in  childhood,  they  may  be  associated  with 
peculiarities  of  development  of  the  nasal  chamber,  esjjecially  a  high 
arch  of  the  palate. 

In  normal  conditions,  there  is  a  di.stinct  |)rotective  function  exerted 
l»y  the  nasal  nuicosa,  which  is  at  once  highly  sensitive,  strongly  vas- 
cularized, and  richly  supi)lied  with  mucous  glands;  as  a  result,  irritation 
is  followed  by  marked  reaction  with  a!)U!idant  nuicous  secretion,  which 
protects  the  epithelium,  washes  off'  and  dilutes  the  irritant,  and  supplies 
a  physical  impediment  to  bacteria. 

The  Pharynx.-  Assistance  is  lent  by  the  pharynx  in  these  processes, 
and  while  its  surface  is  not  multiplied  like  that  of  the  nose,  the  sudden 
change  in  direction  imparted  to  the  air  current  assists  actively  the 
entanglement  of  foreign  particles;  the  abundant  jjrovision  of  lymph 
tissue  (including  the  tonsils)  is  directed  to  this  end,  and  it  is  notable 
that  many  of  the  air-borne  diseases,  such  as  the  exanthemata,  are 
connected  with  a  preliminary  infection  of  the  pharynx. 

The  Larynx.  The  main  function  of  the  larynx  is  phoiiation.  The 
larynx,  essential  for  the  singing  voice  is  not  essential  for  speech;  the 
"note"  of  the  voice  is  determined  by  the  tension  and  the  rate  of  vibra- 
tion of  the  voca!  cords,  and  by  communication  of  this  vibration  to  the 
air.  The  voice  is  therefore  aff'ecte<l  by  the  pathological  states  of  the 
vocal  cords,  which  may  be  thus  divided:  (1)  excessive  nervous  stimuli 
lead  to  spasmodic  contraction  of  the  laryngeal  muscles,  with  closure 
of  the  aperture;  dciective  or  arrested  stimuli  lead  to  flaccidity;  and 
(2)  intrinsic  disturbance  of  the  cords,  such  as  diffuse  or  local  inflam- 
matory thickening,  or  dcveloj)ment  of  tumors  upon  them,  by  which  the 
cords  become  "muted."  Articulation,  on  the  other  hand,  is  dependiiit 
on  the  lips,  teeth,  palate,  and  tongue,  and  it  is  by  disturbances  of  these 
that  it  will  be  affected. 

The  site  of  the  vocal  cords  is  the  region  of  the  greatest  narrowing  of 
the  respiratory  passage,  and  at  this  point,  therefore,  a  relatively  incon- 
siderable stenosis  by  spasm,  inffammatory  deposits,  or  new  growths,  may 
ussume  imjK)rtance;  in  addition  to  tlii.s,  the  larynx,  as  a  whole,  !■;  a 
relatively  narrow  part  of  the  tract,  and  even  slight  affections  of  the 
glottis  are  apt  to  cause  grave  obstruction.    The  relatively  loose  attacli- 


mi 


*r«5f^jfe 


THE  RKSl'IRATOKY  MECHANISM 


429 


ini'iit  (»f  the  mucosa,  except  over  the  vocal  cords,  renders  (inlema  a 
coiiHiH)!!  event,  in  which  the  upper  opening;  of  the  glottis,  the  epiglottic 
and  aryteno-ei)ij;lottic  fol«ls  may  he  so  swollen  that  unless  intul)ation 
or  tnu'heotomy  lie  perforine<i,  asphyxia  may  ensue. 

The  Trachea  and  Bronchi.-  'I'hese  are  lined  hy  moist,  ciliated  mucosa, 
wliicli  is  enahled  to  take  up  many  particles,  and  pass  them  hack  to  he 
rcnioved  h\-  coujihinji;  the  trachea  is  kept  expanded  by  a  series  of 
ciirtihifjiiious  hoops,  which  allow  much  mohility  of  the  tube;  yet  there 
may  he  hindrance  of  respiration  hy  (1)  foreign  hcnly,  (2)  deposits  or 
KPiitractioiis  from  infhunmatioii,  (.'<)  new  growths,  or  (4)  pressure  from 
iiiitsidc,  such  as  would  he  produced  by  aneurysm,  goitre,  mediastinal 
iiirnors,  and  sometimes  even  by  enlarged  tuberculous  lymj)})  nodes. 
\al\ular  obstruction,  permitting  inspiration  but  interfering  witii 
(  Npiration,  may  occur  with  a  diphtheritic  membrane  or  a  polyp.  Asthma 
i^  -iipi)i)sedly  due  to  a  spasm  of  the  l)ronchi  and  bronchioles  suddenly 
produci'd  through  nervous  mechanism;  not  only  is  there  a  spasm  .so 
l)riHlucc(l.  but  evidently  a  rapid  congestion  which  is  so  great  as  to 
iifiMiUMt  to  angioneurotic  iedema  with  abundant  secretion. 

Complete  obstruction  to  the  air  passages  ends  quickly  in  asphyxia; 
with  obstruction  to  inspiration  the  inspiratory  act  becomes  slow  and 
lalpored.  even  to  stridor,  the  expiratory  act  short  and  unimpetled;  the 
iliapiiragni  contracts  more  fully,  ami  the  accessory  mu.sdes  all  aim  at 
iiiiTcasiiig  the  capacity  of  the  thorax;  in  expiratory  dy.spna'a,  the 
;ilnloininal  and  trunk  muscles  aim  at  lessening  the  thoracic  capacity. 
Wlicre  one  main  bronchus  is  obstructed,  there  is  rapid  respiration  until 
.iilaptation  is  secured,  after  which  one  lung  continues  to  perform  the 
work  ordinarily  done  by  both. 

The  Muscular  and  Nervous  Mechanism  of  Normal  Respiration. — 

Inspiration  is  an  active  process,  and  exj)iration,  largely,  if  not  entirely, 

I  pa■^si\(•  one,  brought  about  by  pressure  upward  of  the  abdominal 

i-rcra  (luring  relaxation  of  the  diaphriigm,  aided  by  the  elasticity  of 

I  In   expanded  lung  and  of  the  thoracic  wall.     The  groups  of  muscles, 

niririsic  and  accessory,  and  the  mechanics  of  the  act  will  be  found 

il'  tailci!  ill  text-books  of  i)hysiology.     Tiie  different  nerves  concerned 

"  'lie  stimulation  of  these  muscles  appear  to  be  under  the  coordinated 

'  ntrol  of  a  centre,  although  we  are  unable  to  say  which  particular 

.■riiiip  of  cells  constitutes  this  centre.     Afferent  impulses  affect  it,  for 

tiiiilatidn  of   many  different  cerebral   areas  and    peripheral    nerves 

"lilies  rlie  respiratory  act;  the  pulmonary  branches  of  the  vagus  are 

it*    ni(i>t   ini])ortant   afferent   nerves  of  respiration,   and   stimuli   are 

; ''irently   geiitrated   by   the  carbon   dioxide   tension   in   the   blood, 

•   1  iimmI  tension  of  carbon  dioxide  stimulating  the  centre  to  produce 

'  :i-e(|  respiration,  and  reduced  tension  depressing  it. 

Disturbances  of  Respiration.     Sneezing.-  This  is  a  reflex  act,  caused 

i.illy  by  nasa!  irritation  stimiilatii!!:  .-i  lirap.Hi  of  <|i!>  Hfth  ju-rvo,  and 

i-ts  of  a  deep  spasmodic  inspiration  followed  by  a  strong,  quick 

:   lation.     During  the  first  part  o*  the  latter  process,  the  mouth  is 


4.30 


TIIK  RESPIRATORY  SYSTF.M 


closed  hy  tlio  approximation  of  the  «lorsiiiii  of  the  tongue  and  the 
soft  i)alate,  so  that  the  first  jjortion  of  tlie  air  that  is  expelltMl  K<»es 
through  the  nose,  tending  to  drive  before  it  the  irritant  partieles;  then 
the  tongue  and  soft  palate  are  separated,  and  through  this  relatively 
narrow  spare  the  air  is  forcibly  driven,  producing  the  characteristic 
sound. 

CouKhing.-  This  is  vohintary  or  reflex,  the  irritation  in  the  latter 
case  being  in  the  nasopharynx,  the  larynx,  the  lungs,  or  the  pleura-, 
although  it  may  be  in  the  external  auditory  meat  us;  deep  inspiration 
is  followed  l)y  closure  of  the  glottis,  which  remains  closed  <luring  the  first 
part  of  the  strong  expiratory  effort;  the  glottis  is  thus  suddenly 
"blown"  open,  and  the  released  air  may  carry  with  it  mucus  or  other 
matter  from  the  parts  of  the  tract  that  lie  below. 

Dyspnoea. — This  term  denotes  two  different  states,  that  of  air- 
hmiger,  and,  more  correctly,  that  of  labored  insjuration,  <lue  to  absence 
of  an  adequate  amount  of  air,  or  to  the  accimiulation  of  carbon  dioxide 
in  the  blood,  with  or  without  deficiency  of  oxygen.  It  may  or  may  not 
be  accompanied  by  cyanosis;  the  individual  is  protected  by  being  com- 
pelled at  once  to  re<luce  his  muscular  activity,  diminishing  forthwith  the 
call  for  oxygen  ami  the  discharge  of  carbon  dioxide.  If  the  venosity 
of  the  blood  be  acting  upon  the  centre  for  some  time,  there  develops  a 
lowered  sensitiveness  of  the  centre  which  becomes  accustomed  to  a 
tensicm  of  carbon  dioxide  that  could  not  be  borne  if  suddenly  presentt-d; 
and  there  are,  on  the  cimtrary,  states  of  hypersensitiveness  of  the  centre, 
such  as  are  seen  in  hysteria,  in  which  rapid  respiration  is  produced 
without  there  being  any  evidence  of  a  modificfl  gaseous  tension. 

The  conditions  in  which  dyspno-a  manifests  itself  are:  (1)  conclitions 
of  hindrance  to  the  entrance  of  the  normal  amount  of  air,  (n)  in  the 
air  passages  (foreign  body,  stenosis,  etc.),  {h)  in  the  lungs  (collapse, 
exudates,  growths,  cavitation,  emphysema,  etc.). 

2.  Diseasetl  states  of  the  muscular  mechanism:  (a)  inflannnation  of 
the  diaphragm  or  other  muscles,  (6)  diseased  states  of  the  centres,  the 
afferent  or  efferent  nerves. 

3.  Where  the  circulation  of  the  blood  through  the  lungs  or  the 
medulla  is  obstructed. 

4.  When  the  inspired  air  is  rarefied,  or  carbon  monoxiv!e  is  present  or 
carbon  dioxide  increased  above  normal,  the  two  latter  states  reducing 
the  gaseous  interchange. 

Asphyxia. — In  dyspnoea  a  sufficient  gaseous  interchange  is  ol)taine<l 
to  support  life,  but  in  asphyxia  even  this  minimum  is  not  obtained,  and 
the  accumulation  of  carbon  dioxiiJt  goes  on  until  the  action  of  the  respi- 
ratory centre  is  arrested.  Death  may  follow  prolonged  cyanosis  without 
struggling,  but  more  often  an  intense  respiratory  struggle  occurs.  J" 
this  acute  form  there  is  first  of  all  increased  amplitude  and  rate  of 
respiration,  followed  by  relatively  great  expiratory  efforts,  with  short 
convulsive  insi)irations,  the  expiration  being  accompanied  by  violent 
muscidar  efforts  of  the  entire  body;  as  this  passes  off,  the  respiratiuns 


THE  AIR  SACS 


431 


l)»-('ome  slow  and  deep;  the  inoutli  is  open,  the  head  stretche<l  hack,  and 
tlie  arms  are  raised;  there  is  iiisensihiHty,  the  pupils  are  dilated,  and  the 
respirations  heconie  slower  arul  slower  until  death  ensues.  Coincident 
changes  in  the  hl(H)d  pressure  are  to  he  noted;  there  is  a  marked  rise 
in  pressure,  the  venous  hlood  stimulating  the  vaj^us  and  vasomotor 
ct  litres,  so  that  the  heart  is  slowed  and  the  arterioles  contracted.  The 
liciirt,  poisoned  l>y  venous  hioml,  hegins  to  fail  and  to  distend,  and  the 
liliind  pressure  hegins  to  fall. 

Cheyne-Stokes'  Respiration.-  This  consists,  to  (pKJte  Stokes'  own 
>Mir(ls,  in  "the  occurrence  of  a  series  of  inspirations,  increasing  to  a 
maximum,  and  then  declining  in  force  and  length  until  a  state  of  appar- 
I  lit  apno'a  is  reached;  in  this  condition,  the  patient  may  remain  so 
long  as  to  make  his  attendants  believe  that  he  is  dead,  when  a  low 
inspiration,  followe*!  by  one  more  decided,  marks  the  commencement 
111  a  now  ascending  and  then  descending  series  of  inspirations."  It  was 
iiri;;inally  supposed  that  this  phenomenon  marked  onct.ming  death,  but 
^li.  !i  is  not  necessarily  the  case.  There  are  two  main  groui)s  of  di.sease 
in  which  it  may  be  manifest  circulatory  disease  without  obvious 
(i'-rase  of  the  brain,  and  intracranial  disease  without  affection  of  the 
ill  art;  some  cases  of  general  infection  and  some  narcoses  may  also  show 
it.  It  is  not  possible  in  the  ])resent  state  of  our  knov.Iedge  to  give  any 
sitist'actory  explanation  of  the  phenomenon;  it  appears  to  be  what 
Iiliy>i(ists  call  an  interference  curve,  that  is,  it  is  the  resultant  of  waves 
111  line  rhythm  on  which  are  superposed  waves  of  another  rhythm,  the 
-nni.il  at  times  augmenting,  at  other  times  neutralizing  the  first. 

The  Air  Sacs. — If  oiic  considers  broadly  the  diseased  states  of  the 
air  sacs  tliat  interfere  with  the  proper  performance  of  the  work  of  the 
luiii.'^,  these  fall  into  two  main  groups— those  in  which  the  ingress  of 
air  into  and  the  egress  of  air  from  the  air  sacs  is  prevented,  and  those 
ill  wliicli  cliangcs  in  the  walls  of  the  air  sacs  prevent  the  proper  inter- 
(liaiiL'c  of  gases.    Diseases  of  the  first  order  may  lead  to  those  of  the 

^I'Clilllj. 

Air  iiKiy  he  j)revented  from  entering  the  air  sacs  because  they  have 
iini  liccn  (iisteiuled  (atelectasis:  'ir£/!j'c,  incomplete :  .^'"a'^'C,  expansion) , 
IT  li.iviiig  been  disteiideil,  they  have  undergone  collapse.  If  of  small 
I  \iriii,  this  state  is  of  no  moment,  the  other  air  sacs  undergoing  com- 
|ini  iitiiry  cnlargeiiicnt;  even  a  whole  lung  may  be  thus  dispensed  with, 
il  i!  1  liiiinge  be  wrought  gradually. 

"  'I  met  ion  to  Air. — The  air  sacs  may  become  filled,  and  the  air  they 

iil'l  ciiiituin  be  replaced  (1)  by  serous  fluid,  as  in  the  cases  of  acute  or 

II   congestion,  (2)  by  blood,  as  in  rupture  of  a  branch  of  the  pul- 

!>  artery  in  a  cavity  or  its  walls,  or  in  rupture  of  an  aneurj'sm  into 

'  :.ii  lua,  or  in  infarct;  (3)  by  water  or  other  fluid  from  without,  as  in 

ing;  or  (4)  by  inflammatory  exudate  as  in  pneumonia.    The  effects 

!     of  these  upon  res|)iration  depends  partly  upon  the  amount  of  lung 

iiiMitvcd,  and  partly  upon  the  causative  agent.     In  hemorrhage 

I II huts  of  hemolysis,  or  in  pneumonia  the  toxins,  may  induce  a 


>!;.: 

ci.r 

Mil.! 

tl,. 

ilrn 

of.! 

ti- 

tllC 


•-.•-    '3W:*i 


4:?:. 


77/  H  liKSl'l  UA  TOR  Y  N  I'.S  TKM 


r«l>rilf  stilt*'  whicli  of  its«-lf  will  afT«-<t  n-spiriitioii,  or  tl»-  vVlwi  \\\m\  the 
|)Uura  ill  tlu-  latter  (lisfiisi-  may  hv  rcsponsihlc.  Witli  a  Hiiiil  in  the  air 
sacs  thore  is  a  (frtaiii  iiitfrffreiici'  with  tlu-  ciniilation  in  the  vessels  in 
the  walls  which  are  conipri-sscil  or  not  acconlin^t  to  the  greater  or  les^ 
distension  of  the  sac;  if  this  compression  of  the  cajiillaries  affect  a 
s[H'ciall.v  lar^e  ainoiint  of  IniiK  tissue,  the  result  is  a  larfje  amount  of 
work  thrown  on  the  right  heart,  with  consecjueiit  dilatation,  and,  it 
may  l)e,  hypertrophy. 

Chaiigen  in  Ihv  U'nih nffhr . I ir  Sock  Hindering  Aeration.  -These  chanRes 
may  lie  atrophic  or  may  consist  of  interstitial  dejiosits  in  the  wulls  of 
the  air  sacs.    Of  the  former,  the  most  important  is  emphysema. 


ii   i 


S.rii..i>  (ruin  luii«  ^'h<l»inK  Miffuw  ci„|ili>«iria.     Nut.-  the  iirciil   air.iphy  ami   thinning  of  iilvrdar 
walls  nml  thi-  fri*  inils  nf  ruptunil  anil  iilisorbiil  inlcTulvii)lar  septa. 

Emphysema.  This  ma\-  Ik-  local  or  generalised,  hut  the  mode  of  \m>- 
duction  is  alike  in  both".  The  hronchus  or  bronchiole  has  its  liinieii 
narrowed,  either  l)y  ^pasin  or  hy  inflammatory  dejjosit,  or  by  the  pres- 
ence ill  it  of  thick  secretion;  the  forcible  inspiration  foIlowe<l  by  the 
relatively  passive  act  of  cxjiiratioii  leaves  an  amount  of  air  in  the  sac 
sufficient  to  distend  it;  successive  acts  of  inspiration  will  distend  it  still 
more,  ant'  at  no  time  will  the  sac  attain  the  pru\)eT  degree  of  collapse. 
This  constant  state  of  relative  distension  will  keep  the  capillaries  in 
the  wall  c(miprt.sse.i  'Fig.  217),  fiatteiuHl,  ami  elliptical  in  section:  not 
onlv  do  thev  .  titam  less  blood  than  when  they  are  circular,  but  the 
smaller  amount  of  blood  is  exiM)se.l  to  a  larger  surface  and  iiun.ised 
j-ri^.*:,.,,  xhe  tina!  result  of  this  is  crmtiniit d  malnutrition  of  the  whII, 
reduced  ga.eou>  interchange,  dimiiUKion  of  the  elastic  tissue  and  ot  the 
elasticity  .  t  the  wall,  and  atrophy.    In  this  state,  the  sudden  iiurease 


THE  I'LFVRM.  (  AMTIKS  4;{;{ 

.A  I.hI,.s.  I....IS  u,  t\w  rnptnn.  „f  u ,.,.k..„..,|  walls  „.,.l  M-v.-ral  air  m' 
..r.  .I.rou ,,  ,„t..  n.u-.  I  vn.  if  tlu-  ..Lstructi,,,,  i,.  the  hronc-l,  Z  tZ 
n  ..H.V...I  tlu-  .la,na«..  aln.a.l>  .1..,,,.  is  ,H-r.„ann.t.  an.l  th.-n-  is  aw" 
M  prup..r  pn,,K,rt...M  iM.tw.r,.  .l.,-  (iiun-as...!)  u.huuv  of  air  an.l  .• 
>.  Mnm.slu-.l)  area  ..f  wall  prrsnit.,!  I.v  ,1...  „ir  sa<s.  Tlu.s.  ai  su^ 
>.tHa,...|  at  tlu.  .s„rfa,r  of  tlu-  Ium^.  a.al  ..sp..,.ia||v  at  th e  hirXs 
.."..  n-lat.v..  V  l.ttl..  support..!  I.v  a.ljoi„i„«  'air  sa.-s  suffer  the  Kr,-a  es 
.li>t.;„.H,„.  so  that  thev  ,uay  he  ••hall..oue.l"  to  »  verv  lari;e  sixe 

\N.-  hav  .ousKhr*.!  m  «  Keuerai  way  tlu-  .ausation  of  en.phvsenia- 
•t  will  he  se,  M  that  au.vthiMK  whi.-l,  .auses  a  hei^htene.!  h.tra  I  u^  m  v 
pre.s„re  ,„ay  uuluee  this  state,  hen.-e  the  liahilifv  of  ,.lave'  S 

..ptnuuents    o,    ,las.shlow..rs.  au.l  of    persons  •sulfe'rinKfn.n. 
-Isease  as  whoopu.^  eo„,,h;  a^e,  too.  has  a  .lefinit,.  eff.rt.  in  tha      h 
.  a>  u.ty  of  the  alveolar  walls  is  lessene.l  l,y  the  atrophv   .f  the  "last  • 
..ssue.  an.l   proper    ..ontra,.t,on  of  the   air  .u-    in  expiration    is  , alt 

With   this  emphysematous  expansion   of  the   lungs,   the   .-onstant 
;  <'-..Hl  f..r  ..xygen  ealls  for  an  o^erfillinK  -f  the  ain.u  v  full  a     s"e 

ntmg  the  state  m  whuh  its  maxnnun.  inspirat<.rv  eapaeitv  is  ,ttain«^• 
H    ..xp.ratory  part  of  tlu.  ac-t   is  length ene.l,  gaseous  i  tm-  a  !     is 
I  -  HKH-nt.  the  passage  of  l,|oo,l  through  the  lungs  is  ,,h  C  e    '.„ 
.■..^.arrassment  o(  the  right  si.le  of  the  heart  follows  ' 

Bronchiectasis       This  is  a  ...ulition  of  the  l.ronehus  in  whieh  its 
l"-.Mn  ,s  .hiate.    u,  one  or  n,a,.y  places;  either  hv  pressure    r.n      it  I  , 
"{•"■'  an  atropM<.  wall,  or  I.v  traetion  from   u  itn.ut  le  .     r    .  j '^ 
I.  .mus  ,.oMne,-t,ve  tissue,  tlu-  lumen  of  a  hronc-hus  ..r  a   .  on  S      nm 
>l  ou  a  Ins,  .,r„.  or  .-ven  an  al.ruptly  sa.rular  wi.iening     le   !    ..m- 1 
.n.n.  M.s  takn.g  up  spac-e  that  shonhl  !.<■  ocrupie.l  bv  .t  rll  ai    ^ 
n  >nltn,g  ni  .lunuushe.l  aeration  of  the  W..o,|  ' 

Interstitial   Deposits.       It    is  self-.,  i.lent    that   new    fssue    whetlur 
f-lTo..s  granulomatous.  ..r  ne..plastie  takes  up  n-om  in  the  I   ,',.  „  ,     " 
;;;  ■•;"..  .hsphues  n.,rmal  air  spaee:  hut  this 'i-  „ot  al  .     ,r  i    .'h^^^^    j^^ 

;l:;;t;;;;;'^;,;^i;|;r  •-*•''-••- - 

l-'t  ,,  i '  ..  V?.  '"t'''"'T'  ^'"^P""^'""  »"'!  contraction  would  go  on 
-ti;^  e  ;  wo  1  t;r;  "f  "••=  ^'^y^,  l*''  ''iaphragmati/eon. 
■<  iti,  litt!..  of  th.  a  le  *-"■  *  •r^'^V"^'""  ''f  t''^  lower  parts  of  the  lungs 
'I ''t    reg  ou      The  U    "'^*'"''"".K''  "^  "i-"  ^culcl  he  slight  in 

.^."^Mon.      Ihere  ,s  normally  a  negative  pressure  in  the    pleural 

2b 


il  i 

'  i 

li  : 
i  I 
I    •■ 

I  : 

!■ 


i  i 


II 


434 


77//.  UHsi'in  \T(H(y  .^)>irt:.M 


PneomotboTu.  Tin-  niirarur  ..I  nir  or  pi-  into  one  or  hotli  of  the 
cavities  eliaiiges  this  ntnative  to  n  p(»>iti\e  [iressiire,  aiul  in  rieiirly 
every  cuse  a  (((inpression  ot  the  hiiin  is  pr«Mluee<l;  in  some  cases,  too,  the 
air«lruwn  in  at  inspiration  is  not  expel|.'.l  at  expiration,  and  there  may 
nltimat.  ly  he  a  pressnre  in  the  pleura!  cuity  arvu-'  lan  that  «.f  the 
attnosi)h<re.  VN\  spmk  of  twif<)rnisof  pnen.nothora.v  apsn.  where  there 
is  free  .(.nuiunii'Ution  wilii  the  external  air  thmiigh  the  thoiiu-ic  wall 
or  through  the  i.mik.  and  doted,  where  the  opening  has  l>een  iK-elu(ie<l, 
or  wh<-r.-,  as  in  p'seoiis  uneuniothorax,  no  "iieninR  to  the  air  has  existtnl. 
In  op«  II  pneumothorax  there  is  necessarily  a  positive  pressure  in  the 
pleura,  and  the  lim«  eol!aps<"s  unless  held  by  pleural  adhesions.  In 
closed  pneumothorax,  aeeordinR  to  the  amount  of  air  or  gas,  there  may 
be  merely  a  diminuti«)n  of  the  neRative  or  a  low  positive  pressure  which 
is  not  sufficient  to  entirely  prevent  respiration. 

Plearal  Effusion.  -.\t  first  consideratio..  one  Aould  exjMvt  that  the 
eircet  of  an  ettusion  into  the  pleural  cavity  would  be  to  diminish  the 
space  available  for  the  Iuuk,  and  that  the  elTect  upon  the  lung  would 
be  to  prevent  its  expansion,  just  as  would  a  j)ositive  pressure  uim)ii 
its  surface.  In  etfusioiis  of  hiru'c  amount  this  seems  to  l>e  the  cuse, 
ami  the  lung  lies  against  tiic  vertebral  column  completely  collapse,l. 
In  small  elfu.sions,  the  fluid  by  its  weight  exert  a  lu-gative  pressure,  and 
the  lung,  instead  of  swimming  U{)on  the  effusion,  supports  the  effusion 
until  its  weight  exceeds  the  lifting  power  of  the  lung;  when  this  happens, 
the  fluid  is  able  to  ex«'rt  a  direct  dowu  vard  force  on  the  diaphragm. 
In  such  a  case,  the  partly  compresse<l  lung  has  little  chance  to  exert 
its  elasticity,  and  the  movement  of  the  diaphnigm  and  the  aistal  muscles 
has  to  take  place  against  resistance. 


SPECIAL  PATHOLOGY  OF  THE  RESPIRATORT  SYSTEM 


THE  NOSE 

AnonuOies.-Midformations  of  high  grade  are  generally  associated 
with  important  defects  of  tlu'  face  and  even  of  the  cerebrum  and  are 
important  chiefb"  as  curiosities.  Practically,  the  commonest  anomaly 
is  a  deviation  of  the  bonv  septum,  which  occurs  with  great  frefiiiency. 

Circulatory  Disturbances.  -Hyperemia  of  the  active  sort  occurs  in  m- 
flaramator^•  processes,  and  in  infective  fevers  such  as  measles,  inHueiizii, 
and  even  tvohoid  fever,  and  readily  leads  to  hem«>rrhage  (eputans). 
Of  the  passive  sort  are  those  hyperemias  due  to  heart  and  lung  disia-es, 
and  to  the  presence  of  tumors  in  the  nasal  cavity.  By  reason  ot  the 
delicacv  of  structure  and  the  elasticity  of  the  mucous  membrane  ot 
the  nnse,  it  is  prone  to  be  readily  rendered  hyperemic  m  a  reflex  ua>, 
and  vasomotor  turgescence.  even  of  purely  nervous  origm  is  'retjij.i.i, 
even  so  slight  a  thing  as  a  change  of  posture  in  some  mdivi.luais 


-TaiSTK.. 


THK  \OSE 


435 


.nay  rause  the  rlisaprK-Jiraiuv  -.f  hyiMT.-...;,,  of  on.,  si.lr  of  the  nose 
|hhI  >ts  trnnsfm..,.^.  to  the  other.     Ken.orrh,.,.-  o,.,.urs  i„  ul.rration 

InlUnunation.  -Acute    Rhinitis.    Coryia.    or    C.t«rTh.-This    arises 
i.nmar.ly  from  barter.al  ...fection,  ami  a,.,mrently  from  ex-i„,snre  to 
."M  an.    wet,  as  well  as  .rntatniK  .hemieal  x apors.    Son..-  Jrs..ns  are 
M.MTptihle  to  (rrta.n  iiHhvHual  volatile  s.:l,stancfs.  sn.has  irn-ctt,. 
nml  ...any  to  the  irntant  effect  of  s,H>eial  sorts  of  jH.ller..  the  smell' 
nl  ..Tt,.,.,  flowers  or  ammals;  the  most  familiar  example  of  this  i, 
hay    ever.  wh„.h  ,s  evaleutly  a  reflex  .  .somot..r  effeet  resulting  from 
."i^U.hylax.s.      I  hat  eoryza  i.  met  wit.      .  measles,  sc-arlatina.  variola 
Mtlnn./a.  ami  typhus  fever  probably  n.eans  that  a  .lireet  infection  o 
til.  mucosa  by  the  spccihc  a«ent  .K-curs.    The  mucosa  is  swollen,  hvper- 
.m.. ,  ot  a  .lcqM.ne(l    olor,  .Iry.  an.!  irritate.l.  a  state  soon  follow^  by 
lie  .„p,o,,s  secretmn  of  a  clear,  waterx-.  sliRhtly  viscid  flui.l.  containing 
In.k.Kvt.-s  ami  epithclmm.  and  possesse.1  of  the  power  of  ermling  the 
'km  or  anot  u-r  mucous  membrane.     It  must  Ih-  remembcre.1  that  such 
iM,  mfectio,.  has  the  poNN .  •  t„  sprea.l  to  the  throat,  th.-  accvssory  cavities 
an.!  sumses,  as  well  as  to  the  Kustachian  tube  an.l  the  n.i.ldle  ear     In 
>.vere  prunary  n.tection.s,  as  well  as  after  the  continuance  of  mild 
f.rt,onstlu  fluid  may  iH-come  purulent,  an.l  lu-ing  so  mav  be  mixed 
«  t  i  blood  an.i  maN  possess  a  foul  odor.    Local  abscesses  or  "the  erosion 
<>    l-nc  or  carflage  may  follow.    Me-r.-..^anou«  inflanunation  is  mos 
■'tl.M  due  to  the  .In.htheria  bacillus. 

Chronic  Rhinitis,     fli/prrtrophlc  Hhinills.—r]. 
<"ii:restion.  either  h-    i  infection  or  mechanical    ,  ; 
h  iHTtrophic  changes  in  the  mucous  meml>rane.      >■ 
pla-r  Ml  the  sul. mucous  tissues,  and  mav.  in  ext  •  . 
I"'l  l-i.l"!  form    he  merely  to  the  foldings  of  t^       .  ,    .     proper     in 
...n..  ...  ,  suc^h  hypertrophy  is  followe.l  by  a  secondary  contraction 

•■"l"ig  t,,  a  dimumtion  m  the  size  of  the  turbinate,  the  so-called 
......dary  atrophy"  seen  in  old  persons.     This  process    ho^-^ii 

-'H.tlnng  ,pute  apart  from  the  condition  of  atn.phic  rhinitis,  as  will 

;■ .  ^:;;n  m  the  description  of  that  state     The  old  icL  tha^  .n  atrophic 

f.I'l!.tiom  ^    ^'      "  hypertrophic  .-ondition  seems  %,  be  without 

Alroj^lnc  nhi,,ith -~rhUcoiu\h\on  has  been  the  object  of  innumer- 

l'';<l>scuss.ons  ami  n.v.-tigations  as  to  cause,  and  very  variedTon- 

'     -n>  have  been  reached.     The  condition  p;esents  a  very         nke 

-;al  and  also  histological  picture.    The  stn.ctures  in  the  nos.  "  *' 

1.  shrunken   and   covered  with  .Iry.  foul-smelling  crusts  (oz,n, 

'  '  •  histological  pic-ture  shows  m.rked  thinning  of  the  mucosa    wiih 

.         iinthfhuvi  from  c-olumnar  to  sqi-.-mou^.    There  are  changes  in 
'    .0.-S,  which  some  observer,  n  ,ard  as  th.    primary  factor  fn  the 
!-"i    ,.on  of  the  disease,  though  this  we  are  ,u,t  inclined  to  admit 

i^t  formation  takes  place  for  two  reasons-there  is  abnormal  air 


•  Z  continuance  of 

t,M!  ,  may  lead  to 

'  •  •i^triifowth  takes 

1';  ''a.-.  .,  assume  a 

proper.    In 


i 

m 


m-' 


435  '/•///;  HKSriRATORY  SYSrE.\f 

span-  in  tlu-  ....st-  tvuduMi  to  .Iryii.K'  of  tlu>  sem-tions.  an<l  tl.m-  is  a 
markcl  .Uminiiti..n  in  the  amount  of  tlu-so  somtK.ns.  due  to  thr 
(It'stnirtion  of  tht-  st-m-tinn  ^'lii'i'l^*-  .     ,     .  ,  .•.-      i 

It  se.«ms  probable  that  we  have  here  t..  <leal  with  a  eon.lit.on  havu,^' 
a  verv  varied  eti<.lo«v  in  .litVerent  cases.  There  may  be  m  some  eases  a 
eon«M.ital  peculiarity  in  the  distrib.itiou  of  the  s,,uam..us  ep.thelnun 
in  t'u.  nose  an.l  in  the  width  of  the  air  spaces,  but  nu.re  often  ,t  >s 
probablv  the  result  of  some  former  se^(■re  n.Haminatory  process  which 
has  destroved  the  normal  lining;  of  the  nose,  and  this  has  been  imper- 
fectlv  repaired.  Such  seNcre  .lestruction  may  be  seen  in  congenital 
svphUis.  and  in  the  infec-ti.nis  fevers,  such  as  scarlet  fever.  In  some 
cases  a  l..ii>;-coiitiiuied,  latent  suppuration  in  one  oi  the  accessory 
sinuses  mav  be  the  cause  of  the  disease.l  state. 

The  Granulomas.-  Tuberculosis  in  the  nose  is  rare,  syphUis.  how  \er. 

is  fairlv  often  seen,  bc,'in.mm  with  the  "snuffles"  of  the  baby  who  is 

b..rn  s'vpliilitic,  with  a  constant  i»urii!eiit  catarrh;  minima  is  apt  to 

arise  in  the  c-artilages  or  bones,  and,  when  broken  down,  Jo  K.ye  .,n«in 

to  the  "sad.lle"  deformity  so  often   seen;  pert<.ratioii  ..I  the  septum 

aiKl  of  the  hanl  palate  may  occur.    Glanders  and  leprosy  may  attack 

the  nasal  mucous  membrane,  the  lesions  varying  according  to  the 

acuitv  of  the  infection.  ,   .     , 

Progressive  Changes.    The  most  <-omiiion  torm  ot  overgrowth  is  thi 

polvp^md.as  has  been  reiharked  elsewhere,  the  polyp  is  usually  n..t 

a  tu  m.r  pro!)er,  but  a  mass  of  proliferated  tissue,  which  thus  becomes 

OBdematoJs  ..r  a   myxomatous  polyp.     Both  are  gray,  semitranslucent, 

and  sparselv  cellular;    mucous  «l..ii.ls   may  be  enclose.l  in  the  ina>s, 

an<l  mav  bm.me  cystic:  pn.liferation  ..f  the  >;landular  parts  may  inuKe 

adenoma,  of  the  Hbn.us  parts,  fibroma,  and  widening  ot   the  vesse  s 

telZiec  asis.     One  must  at  times  be  ama/.d  at  the  sr/.e  ot  .edematous 

or  myxomatous  polyps  that  can  be  taken  from  the  m.stnl.       arcinoma 

arising  i.rimarily  is  rare,  sarcoma  ni..re  common.     New  gn.vvths,  ..ft.n 

endotheUomatous,  arise  in  the  acc»ssor\    sinuses. 

PHARYNX  AND  TONSILS 
Fauces.     .\s  the  gate  of  common  entry  to  two  important  systems, 
the  .ligcstivc  and  the  respiraf.ry.  the  pharynx  is  ,  lara.teri/.ed  l^  wha 
would  appear  t<.  be  an  extensive  .lefensivc  mechanism  in  the  sl.aiK 
;;;  allndlnt  submucous  lymphoi.l  tissue.     This  tissue  is  l-sen    .. 
most  of  its  extent,  but  is  massed  in  the  form  ot  ^  cry  numerous  to  I,  U 
in  the  two  lateral  pair  of  faucial  tonsils,  and  m  the  ine.han  super.u     r 
nharvngcal  tonsil.   The  structure  of  these  tonsils  is  <-liaracteris  ic    1  u 
■niderin  is  relativelv  thin,  an.l  .lips  .lown  f..rn.ing  a  .•..lle.tion  ot  .rvpts. 
t  the  surfaVe  an.l  imine.liatcly  be.u-ath  the  epithelium  hn.n 

;;!:  ..vpts  is  a,,  abmLlant  ..ollecti.,,.  of  lymph  foUu  es.    A  sn..r  m 
with  a  swab  rev.als  fairly  numerous  tree  p..lymorpl-.  •»''''<';^^ ^^^^ ™ 
have  evi.lciitly  wan.lcrcl  out  an.l  ingest  surface  bactena,  etc.    1  unmi, 


^■"«.'-»  .<«. 


I'llMiYXX     \.\l)  TOSSII.S 


A'M 


ill .  ordiiif;  to  Iawt,  tlu-  tliiii  «|)itlicliiiin  ci.n  i-riii);  the  tonsils  also  posst'ssi-s 
pliM^rocytic  proiMTties.  By  this  means  the  surface  is  kept  clean  and 
lr<f  t'roni  the  j;ro\vtli  of  bacteria  \v:ii<h  have  impinged  njjon  it,  either 
from  the  inhaled  air  or  from  the  foo<l  in  the  jjrocess  of  l)einK  swallowtnl. 
it  will  he  further  noticed  that  the  subnuicosa  is  fairly  loose,  with  a 
riliitiv<-ly  rich  vascular  supply,  and  that  it  contains  numerous  muc«)Us 
irliiiids.  Notwithstanding  these  defences  the  very  position  and  function 
of  the  |)harynx  render  it  lial)le  to  various  forms  of  inflammation. 

Abnormalities.— These  are  uncommon.  Cleft  palate  may  involve  the 
Mitt  |)aiate;  occasionaiiy  the  uvula  is  hifid.  There  may  he  the  openiufr.s 
lit  persistent  gill  clefts  into  the  pharynx,  these  forming;  either  complete 
(JMiilie  extending  to  the  surface,  or  merely  closed  lateral  diverticula. 
Thi  most  striking  abnormality  is  epignathus  (p.  (>."»).  This  teratomatous 
f;rii\vtli,  which  has  its  attachment  at  the  base  of  the  skull,  projects  into 
till'  mouth. 

Circulatory  Disturbances.-  The  vascular  c..nditioii  of  this  region 
iiiid  its  visibility  make  it  a  striking  indicator  of  circulatory  disturbances 
the  active  hyperemia  set  up  by  various  irritants,  with  its  scarlet  re<l 
.il>iii:irjincc,  through  the  more  l)rownish  color  of  chronic  irritative 
liMnriniia,  as  in  alcoholics  and  smokers,  to  the  passive  hyperemia  of 
(.iriii:ic  disease,  with  its  bluish-red  livid  api)earance  and' irregularity 
III  Mirfiice  brought  about  by  swollen  veins.  Pharyngeal  oedema  is  not 
uiiiominon;  most  often  it  is  associated  with  sjjreading  inflammatory 
>t;it.s  ,'. ;•.,  acute  inflammation  of  the  tonsils.    It  may  be  angioneurotic 

I'l  'M r  may  show  itself  in  obstructive  heart  disease. 

Inflammation. Of  this  we  recognize  various  grades.  It  may  be  noted 
tb:ii  liKtd  inHatnmation  (amygdalitis,  of  the  tonsil,  or  uvulitis)  is  apt  to 
-!iri  ail  iind  become  generalized,  setting  u])  a  condition  of  pharyngitis. 
\\r  rii  iignize  the  following  forms: 

Acute  Catarrhal  Pharyngitis.— Acute  catarrhal  pharyngitis  or  angina 
•  \liiiiits  in  the  early  stage  pronounced  redness  and  swelling  of  the 
iiinii.sii,  witii  later  abundant  discharge  of  mucus  or  muropus  and 
>"i  iimi;  of  the  isolated  lymph  follicles,  sometimes  also  of  the  mucous 
siNiii.k.  OvtT  these  projections  there  may  be  abrasions  and  formatitm 
"t  iiii.il  ulcers,  with  gra.x  ish  necrotic  bases,  .\cute  tonsillitis  mav  be 
"t  iliili  rent  types,  but  in  all,  the  tonsils  are  swollen  and  hyperemic.'aml 
lii'r,  1.  abinidant  secretion  of  mucopus.  The  inflammation  mainlv 
■111' IN  tiu.  crypts  which  become  greatly  swoPen  ami  filled  with  foul 
I'"'  ii'  nt  material.  From  here  the  inflammation  may  extend  into  the 
~iil  !inc,.  „f  the  (.rgan  leading  to  tonsillar  abscess, 'and,  as  an  after- 
n   ;i.i  ,,t  the  follicular  disturbance,  the  contents  of  the  crvpts  may 


til 'I 
Ilia 
Wl 
th, 
liii: 

IT. 


1'  Mi>pissate<l,  cheesy,  and  intensely  foul  smelling;  still  later  they 
I'come  the  seat  of  calcarec)us  deposits,  forming  concrement.s. 
ther»'  IS  abscess  formation  the  process  may  infiltrate  through 
'  |KT  tissue  extending  into  the  <-eIlular  tissue 'around  abmit,  with 
iiiliammatory  (edema,  setting  up  the  condition  known  as  quinsy 
'i:i.\  be,  peritonsillar  abscess. 


438 


TffE  liKSrinATORY  SYSTEM 


Phlegmonous  Pharyngitis. — Phlegmonous  pharyngitis,  whether  origin- 
ating from  the  tonsils,  as  above  noted,  or  from  trauma,  or  an  acute 
pharyngeal  infection,  is  in  scarlatina,  erysipelas,  and  diphtheria, 
exhibits  a  pronounced  seropurulent  inflammation  and  infiltration  of 
the  pharyngeal  subnuicosa,  with  extreme  swelling  of  all  parts  of  the 
pharynx  and  dryness  of  the  surface  (which  is  apt  to  be  deeply  con- 
gested and  to  present  occasioiial  superficial  vesicles).  This  condition 
may  subside  or  lead  to  the  formation  of  localized  abscesses,  or,  again, 
to  a  diffuse  gangrene  of  tiic  region. 

Retropharyngeal  Abscess. — Retropharyngeal  abscess  of  the  deeper 
tissues  behind  or  at  the  side  of  the  pliarynx,  may  originate  either  second- 
arj'  to  pharyngitis  or  tonsillitis,  or  to  caries  of  the  cervical  vertebra*,  or 
suppurative  otitis  media,  or,  again,  may  be  one  of  the  manifestations  of 
pyemia.  Such  an  abscess  is  apt  to  bu  "st  into  the  i)harynx,  or  to  extend 
downward  along  the  osophagus.  Ot'ier  complications  are  erosion  of 
the  internal  carotid  artery  (csi)ecially  in  the  case  of  tonsillar  abscess), 
inflammatory  swelling  of  the  cervifal  lymph  nodes,  aspiration  pneu- 
nnmia,  thromboi)h!ebitis,  and  general  bactcriemia. 

Regarding  tonsilhir  and  pharyngeal  inflammations,  there  are  certiiin 
points  deserving  of  note:  (1)  the  high  grade  of  fever  that  rapidly 
supervenes  even  in  the  simpler  catarrhal  conditions;  (2)  the  frequency 
with  wliich  acute  inflammation  of  this  region  ushers  in  severe  general 
infections,  notably  scarlatina  an<l  acute  rheumatism.  Tn  smallpox 
an«i  measK  s  the  pharynx  also  may  be  involve*!  and  not  infrequently 
secondary  sypliilitic  manifcstaiions  of  this  region  lead  to  an  acute 
pharyngitis. 

Membranous  Pharyngitis.  It  iniist  be  kept  well  in  mind  that  while  a 
characteristic  filirinoiis  or  membranous  inflannnation  of  the  pharynx 
i.->  due  most  frc(|uciitl>  to  the  (li|)litlHTia  bacillus,  such  membranous 
inflannnation  is  li\  uo  nuiiiis  a  nccc— -ary  iiidication  of  diphtluTial 
inflannnation.  The  so-called  "diphtheritic  membrane"  may  be  due  tn 
(1)  irdialation  of  steam  and  irritant  gases;  (2)  the  streptococcus 
pyogenes;  ('.{)  more  rarely,  pnciiUKx mccus,  in  addition  to  (4;  the  most 
important  cause.  Racillus  diphtheria'.  In  gmeral  it  may  be  said  that 
the  use  of  diplitlicria  antitoxin  gives  the  most  rapid  difl'erentiatioii 
l)etween  the  diphtherial  and  other  forms  of  inflammation.  With  this 
ti."  leathery  niembraiie  induced  by  the  diphtheria  bacillus  may  loosen 
within  a  few  hours.  The  antitoxin  may  have  some  effect  on  other 
ijiembrjincs.  hut  not  so  rapidly  or  so  characteristically.  The  true 
diphtherial  infection  begins  with  a  localized  congestion  of  the  fauces 
of  the  tonsils  or  back  of  the  p!iar\iix;  soon  there  appear  grayish-wliitc, 
opalescent  spots,  which  sprciid  and  become  fused,  and  now  extending 
over  the  pharyngeal  wall,  coalesce  into  a  dirty  yellowish  t  lembrane.  At 
the  edge  of  tlie  spreading  membrane  is  a  zone  of  acute  congestion,  and 
characten'-tically  the  membrane  in  its  early  stage  is  firmly  adherent. 
Removal  of  the  i-dge  or  other  part  will  be  followed  by  bleeding.  Lfit-T, 
where  healing  occurs  the  membrane  becomes  loosened  and  may  lie 


^TCr 


rswT'Tfvm 


rUAHYXX  AM)  TOXSILS 


439 


removed  with  ease.     Such  iiieiubraiie  may  extend  from  the  pharynx 
into  the  posterior  nasal  passages,  th«-  hi.ynx,  trachea,  bronchi,  etc. 

As  pointed  out  already,  with  the  superficial  growth  of  the  diphtheria 
hac  illus  on  the  surface  of  the  nuicous  membrane,  there  is  a  necrosis 
and  destruction  of  the  epidermal  tissue,  which  is  cast  off,  an  intense  con- 
jrcstioii  of  the  submucosa  with  abundant  exudation  of  serum  and  leuiio- 
( ytcs,  and  now  a  fibrinous  coagulation  of  the  exudate,  with,  at  the  same 
time,  a  necrosis  of  the  superficial  layers  of  the  submucosa.  As  the  cells 
litrt!  undorgo  a  coagulation  necrosis  the  resulting  membrane  is  due  in 
l)art  to  the  surface  exudate,  in  part  to  these  necrosed  and  infiltrated 
superficial  layers  of  the  submucosa.  It  is  this  that  renders  the  mem- 
l)rane  so  firmly  adherent.  Later,  with  healing,  abundant  leukocytes 
pass  from  the  ves.eis  into  the  deeper  layer  of  necrosis,  and  as  these, 
through  their  enzymes,  cause  the  liquefaction  of  the  necrosed  tissue 
the  overlying  mt-ni)rane  becomes  loosened.  Diphtheria  bacilli  may  be 
Mipcrficial  and  grow  in  greatest  abundance  toward  the  under  aspect  of 
the  nunilirane,  although  from  here  they  are  not  to  any  large  extent 
taken  up  by  the  leukocytes  and  conveyed  to  the  deeper  tissues.  Or, 
if  so  conveyed,  they  do  not  there  proliferate  actively.  Almost  con- 
stantly there  is  an  accompanying  abundant  growth  of  streptococci  in 
the  membrane.  These  may  invade  the  deeper  tissues  ai)d  set  up  severe 
lymplieating  disturbances.  Harely  the  inflammatiim  extends  along  the 
Ku-tachian  tube  to  the  middle  ear,  or  through  the  lacrimal  duct  to  the 
eoiijunctiva. 

A  similar  membranous  infection  occurs  m  very  acute  cases  of  scarlet 
It  \  er.  I  !ere  streptococci  appear  to  be  the  main  agents,  and  the  tendency 
tor  tlie  process  to  extend  into  the  deei)er  tissues  with  ulcerative  dis- 
tnrl.aneesaiid  suppuration  oi  the  cervical  lymph  glands  is  much  greater. 

Vincent's  Angina.  Xincent's  angina,  dm-,  it  would  seem,  to  the 
;;r(A\tli  of  spirociietes  with  the  bacillus  fusiformis,  is  a  rare  affection, 
and  may  in  tin  early  stages  show  membrane  formation.  This  tends 
t"  the  de\tl()j)ni.-nt  of  siiperfici;  '  necrosis  of  the  pharynx  with  the 
tiinnatiun  of  ulcers. 

Chronic  Pharyngitis.  The  chronic  form  may  Iw  due  to  recurrent  or 
I'liu-eontiiuied  irritation  as  by  alcohol,  tobacco,  or  may  be  the  sequel 
"I  a  sn(cession  of  acute  attacks.  There  is  a  congestion  of  the  pharyn- 
;:i.il  wall,  with  dull,  reddish  or  brownish  coloration,  a  mucoid  or  miico- 
I'linilnit  secretion  tending  to  dry  and  adhere  in  the  form  of  scales,  and 
it  !i  l-erpiasia  of  the  lymph  follicles,  gi'.ing  the  wall  a  granular,  wartv 
iii'l'>  nance  (granular  pharyngitis).  More  rarely  with  atrophv  of  the 
I'luro-a  the  membrane  becomes  thin,  .smooth,  dry,  and  shiny"  (chronic 
atiophic  pharyngitis).  In  chronic  tonsillitis  with  advancing  age,  as  again, 
•"  '"iiii>:  to  r,on;e,  as  the  residt  of  acut.>  tonsillitis,  the  lymphoid  ti.ssue 
"I  II  •  tonsils  may  become  diniinished  in  amount,  and  there  may  be 
It  atrophy  of  these  organs.    The  ojjposite  condition,  hyiHTtro'phy, 


ti-i, 


•lii     i(-iilt  from   repeated  attacks  of  acute  tonsillitis,  or  from  long- 
'"'   : 'lied  irritation,  as  from  retention  of  inspissate<l  material  in  the 


440 


•77/ a:  ItF.SI'lRATORY  SYSTEM 


tonsillar  crypts.  In  tlu-sr  ciiscs  tlu-  orpins  art-  distinctly  cnlarKccI, 
cxiiihiting  a  ditt'nsc  liypcrtropliy.  so  that  tlicy  may  he  of  the  size  of 
walnuts,  and  may  interfere  with  swallowinj;  and  res|)iration.  General 
hypertr()|)hy  is  particularly  liahle  to  involve  the  pharyngeal  tonsil  in 
ehihlren  and  thus  cause  what  are  generally  known  as  adenoids.  In 
fact,  the  hyi)ertrophic  ty])e  of  chronic  disturbance,  whether  of  the 
faucial  or  the  pharyng<  a!  tonsils  especially  affects  children  a.id  brings 
about  marked  respiratory  disturbance.  In  a  certain  proportion  of 
cases  what  appears  to  l)e  a  simj)le  hyiMTtroi)hy  is  found  by  the  inocula- 
tion of  guinea-pigs  to  be  tuberculous.  While  this  is  the  case  it  is  inter- 
esting to  notv  that  there  may  be  no  rec()giii7,al)le  tubercles  or  caseation, 
but  a  (litluse  cellular  infiltration,  with  overgrowth  of  the  stroma  of 
these  organs. 

As  above  noted,  another  form  of  chronic  tonsillitis  specially  involves 
the  crypts  (chronic  follicular  tonsillitis)  with  progressive  distension  of 
these  crypts  by  desquamated  cells,  etc.,  until  they  become  filled  by 
large  cheesy  plugs. 

Tuberculosis.—  Tuberculosis  may  involve  the  tonsils  and  may,  as  above 
noted,  be  apparently  primary,  and  then  of  an  unobtrusive  type,  or  there 
may  be  pharxngeal  tonsillar  tuberfulosis  secondar\-  to  pulmonary  or 
laryngeal  disease.  In  this  secondary  tuberculosis  of  the  pharynx  the 
superficial  tubercles  break  down  and  form  shallow  ulcers. 

Syphilis.  Syphilis  in  the  secondary  stage  may  show  itself  as  an  acii^e 
catarrhal  inflanunation,  or  there  may  develop  nuicous  platpies  tending 
to  give  place  to  shallow  ulceration.  There  are  cases  of  primary  chancre, 
as  again  of  gummas  of  the  submucous  tissue. 


THE  LARYNX  AND  TRACHEA 

Etiological  factors  of  importance  in  the  causation  of  disease  of  tlic 
larynx  and  trachea  arc  the  characters  of  the  respired  air,  and  of  the 
secretions  coughed  out  from  below  it,  and  the  state  of  nearby  organs, 
such  as  the  pharynx  and  the  thyroid.  Finally,  it  is  of  interest  that  tlic 
phenomenon  of  "catching  cold"  has  this  jjhysiologi.al  basis,  that  aneniiii 
and  hyperemia  of  the  hirynx  can  be  induced  by  the  application  of  lii-at 
and  cold  to  areas  of  the  skin  far  remote  from  the  larynx  itself. 

Abnormalities.  Absence  of  the  hirynx  occurs  in  conjunction  ^^itll 
grave  defects  that  are  incompatible  witli  the  continuance  of  life.  Hypo- 
plasia occurs  in  the  subjects  of  early  castration,  giving  rise  to  the  modifi- 
cation of  voice  often  ol)served  in  such  persons.  The  epiglottis  may  i.e 
fissured,  and  the  sinuses  of  Morgagni  may  be  .so  deep  as  to  form  definite 
pouches.  The  anomalies  of  most  practical  importance  are  atresia  or 
narrowing  of  thi'  tube,  fistulous  communication  with  the  a-sophagus  ami 
persistence  of  the  branchial  clefts. 

Circulatory  Disturbances.  The  laxity  of  the  subjnucosa  is  chit  ll.\ 
responsible  for  the  rapid  ajjpearance  and  disappearance  of  phenoiiit  iia 
associate*!  with  the  blood  supply  of  these  parts. 


TIIK  LARYSX  AXD  riiAClIKA 


441 


Anemia  of  the  larynx  nmy  he  an  early  iiulicatioii  of  systemic  anemia 
(ir  even  of  tiihereulosis. 

Hyperemia  may  result  from  infection,  from  the  efiect  of  dust  or  irri- 
tating gases,  an(l  from  excessive  use  of  the  voice;  long  continuance  of 
liypercmia  may  lead  to  a  permanent  dilatation  of  the  veins  (phlebec- 
tasia  laryngea).  Hemorrhage  may  result  from  trauma,  ulceration, 
licnio;  liiiia,  scurvy  or  phosphorus  poisoning,  and  a  hematoma  so  arising 
lit  this  site  may  cause  suffocation.  (Edema  of  the  glottis  is  the  most 
iin])ortant  circulatory  change  from  a  practical  standpoint.  The  acute 
type  is  generally  of  inflammatory  origin;  the  less  acute  forms  arise  in 
patients  suffering  from  cardiac  or  renal  dropsy  or  from  the  i)ressure 
(if  cervical  or  mediastinal  tumors  or  aneurysms.  Those  parts  in 
w  liich  the  suhmucosa  is  the  most  lax  are  most  prone  to  the  disease,  viz., 
the  aryepigU)ttic  folds,  the  epiglottis,  the  false  cords,  the  arytenoid 
(artilages,  and  less  often  the  vocal  i-ords. 

Inflammatioii. — Acute  Laryngitis. — According  to  the  course  and  the 
intensity  of  the  inflammation,  the  appearance  of  ditt'erent  cases  of 
iillanmiation  may  vary  widely,  and  the  most  striking  feature  generally 
serves  to  give  a  characteristic  name  to  the  inflammation.  Thus  we 
>|H-ak  of  catarrhal,  membranous,  phlegmonous,  or  ulcerative  laryngitis, 
lis  weil  as  of  certain  specific  forms,  such  as  tuberculous  or  syphilitic 
laryngitis,  or  those  occurring  in  variola,  glanders,  leprosy,  or  rhino- 
Mlcnmia. 

('(liarrhdl  I Ji ry ti (jit In. --Thk  represents  an  early  stage  of  inflammation, 
seen  often  by  the  laryngologist,  excitetl  by  a  variety  of  irritants,  arising 
III  the  infective  fevers,  and  is  a  prominent  feature  in  such  diseases  as 
influenza  and  whooping  cough.  Just  as  in  the  nose,  a  preliminary 
n  ihiess  and  swelling  are  followed  by  secretion  of  a  fluid  at  first  clear, 
lati  r  ilou<ly  or  purulent,  not  often  crusting  upon  the  surface.  Super- 
tiiial  erosions  are  common,  and  the  apjxarance  of  traces  of  blo<xl, 
iVoin  lieniorrhage  |)roduced  by  violent  coughing,  frequent.  Influenzal 
iiitictinii  is  often  nasal  at  first,  whereas  that  of  whooping  cough  is 

■  tt(  n  tracheal.  Inflammatory  affections  of  the  larynx  are  assisted  and 
iriit  n-ificd,  and  even  at  times  inauguratetl,  by  the  excessive  use  of 
loliiiim  and  alcohol.     A  definite  ill-eft'ect  on  the  larynx  caiuiot  but 

•  ill  from  the  practice  of  "inhaling"  the  smoke  of  even  the  mildest 
I'  I'lKcii,  to  say  nothing  of  the  greatly  increased  absorption  of  nicotine 
liat  uccurs  through  the  delicate  mucosa  of  the  tract  lower  than  the 
'.l..r,Mi\. 

M<  iiihriiiiiin.y  Ldriftijfititi.-  The  membrane,  due  to  whatever  cause, 

■  'i-i-is  of  fibrin,  moist  with  serum,  entangling  in  its  meshes  leukocytes 

'I  <l(  Mil  (clls  of  the  part,  as  well  as  bacteria.     The  superficial  cells 

lie  killed  and  form  part  of  the  membrane;  a  coagulation  necrosis 

ii.i\c  gone  down  to  some  depth,  and  layers  even  lower  than  the 

a  be  loniprised;  in  such  a  case,  the  membrane  bein;,'  jidled  off, 

v\itli  it  the  upper  layers  of  the  underlying  tissues,  and  a  bleeding 

'   results;  of  this  form  of  itiflammation,  diphtheria  gives  a  good 


442 


77/ A'  RKSI'IRArOliY  SYSTEM 


It'- 


example,  but  it  is  l>y  imi  means  safe  to  rely  upon  this  as  a  sign  by  which 
to  recognize  diphtluTia,  because  a  membrane  overlying  columnar 
epithelium  is  more  nadil:   removed  than  a  membrane  of  like  density 


Fio.  218 


-a 


iihritiu-  rcphu'ing  nuicosa;  b,  outer  layers 


Serticin  frnm  ii  cawe  of    n.cnilirannus  tracheitis:   a,   meilili 
lit  auliiiiueiwa.   necrotie  anil  iiifillrateil   with   Uukiieytei.,  c-,  iiiUMiul.iris   mueojw;  J.  efiguried  veimels 
iif  mihimirosa.  e,  deepest  layer'-  of  suhiniie<iaa;  /,  carlilaKe. 


over  squamous  epithelium,  and 
diphtheria  may  exist  with  any 
sort  of  membrane  or  even  with- 
out one;  and,  on  the  other  hand, 
the  pyogenic  cocci  are  capable 
of  causing  a  membrane  not  dis- 
tinguishable in  api)earance  from 
that  of  diphtheria. 

Phhiiiiionimx  Laryngitis.  — 
Phlegmonous  laryngitis  is  an 
occasional  sequel  of  ulceration, 
or  even  of  iliphtheria  or  erysipe- 
las, and  may  reach  the  cartilages, 
setting  u[)  a  perichondritis;  in 
this  last,  sequestration  of  a  part 
of  the  cartilage  inay  occur,  and 
a  fistula  remain. 

Chronic  Laryngitis.  —  Chronic 
laryngitis,  of  non-specific  onltr, 
leads  to  a  definite  hypertr()i)liy 
of  the  mucosa  and  snbmucusa, 
which  is   sometimes  quite  lixal- 

ized  into  warty,  gray  areas   (pachydermia  laryngis  vemiCMa);  these 

latter  are  often  found  on  the  vocal  cords. 
Tuberculous  Laryngitis. — It   happens  frequently  that  in  ad\;ui(t<l 

pulmonary  tuberculosis  the  larynx  becomes  infected  from  the  bacilli!>- 


Suppurative  perichondritis  of  larj'ni:  o,  infil- 
trated and  necrotic  inner  wall  of  ahaoeas;  6,  eartilaKc 
laid  bare  and  surrounded  liy  abscess  cavit.\. 


THE  LARYNX  AM)  TRACHEA 


443 


latlen'sputum,  with  the  result  that  ulceration  or  a  diffuse  infiltration 
results.  A  tubercle,  caseatiug  and  discharKinj;,  will  leave  an  ulcer, 
(IP  there  may  be  shallow  erosions  whose  relation  to  the  tuberculous 
infection  is  not  at  once  evident,  or  there  may  be  a  diffuse,  granular 
overgrowth,  definitely  tuberculous,  which  may  subsequently  caseate 
ill  it  number  of  places. 

Syphilitic  LaryngitiB. — Like  tuberculosis,  this  may  be  evidenced  by  con- 
jcestion,  a  diffuse  infiltration  or  the  formation  of  gummas,  the  epiglottis 
iiiid  the  vocal  cords  being  liable  to  show  the  lesions.  The  tissues  some- 
times become  rough  and  warty  with  the  overgrowths,  and  in  parts 
where  there  is  considerable  ulceration  a  good  deal  of  deformity  may 
result. 

Glanders,  leprosy,  actinomycosis,  and  rhinoscleroma  are  all  able  to 
j;i\e  origin  to  ulceration  of  the  larynx. 

Fig.  220 


Curcinimia  of  the  larynx.     (From  the  Patholofncal  Museum  of  McGill  I'uiversity.) 

Regressive  and  Progressive  Tissue  Change. —Atrophy  of  mucosa, 
iiliiiiucosa,  muscle  and  cartilage,  calcification  of  cartilage  and  such 
•  haiiKes  occur  in  natural  or  premature  .senescence.  Of  progressive 
'  liaiiges,  the  commonest  is  the  papilloma  or  papillary  fibroma,  a  warty 
excrescence  often  seen  on  the  vocal  cords,  consisting  of  fibrous  tissue 
"\erlaid  by  squamous  epithelium,  which  often  recurs  after  it  has  been 
I'lnoxed  yet  <loes  not  often  show  indications  of  carcinoma.  Like  this 
1-  the  iiiiire  Hattened  nodular  fibroma  which  is  scarcely  papillate  or 
i'lvpoiil,  lound  on  the  vocal  cords  of  singers.  Enchondroma,  lipoma, 
Miyxoma,  lymphangioma,  adenoma,  cysts,  and  even  thyroid  tumors  are 
'"'iiiil  ni  tiio  larynx  and  trachea,  and  carcinoma  is  the  most  frequent 


444 


Tllh:  HESI'lliM'nHY  SYSTEM 


iniiliKnaiit  Krowtli.  usually  of  tlu-  s<|naiin)iis  varu-ty.     Sarcoma  is  rare, 
and  the  larynx  and  traeln-a  arc  not  usual  sites  for  st'f«>n(lary  growth. 

Alterations  in  Siie  and  Shape.  Obstruction  of  the  lumen  may  he 
eaustnl  hy  crdema.  inflainmatory  infiltration,  tumors,  exostoses,  and 
atresia,  or  narrowing,  hy  contraction  of  scar  tissue,  or  as  the  result  of 
l)ressure  from  the  outside  hy  agencies  such  as  thyroid  tuniors,  i)eri- 
tracheal  ahscesses,  enlarge*!  lymph  iukIcs,  or  aneurysms,  most  of  which 
may  idso  cause  perforation  of  its  walls. 


THE  BRONCHI 

The  pathological  changes  found  in  the  bronchi  are  diverse,  according 
to  the  anatomical  nature  of  the  part  affectetl;  the  larger  hroiichi, 
approximating  to  the  structure  of  the  trachea  and  larynx,  are  likely 
to  be  subject  to  changes  similar  to  the  changes  seen  in  those  structures. 
while  the  terminal  bronchioles  are  so  intimately  connecte<l  with  the 
air  sacs  of  the  lungs  that  lesions  of  the  latter  are  certain  to  affect  the 
former. 

Circulatory  Disturbances.  Passive  congestion  of  the  bronchi  is  found 
typically  in  connection  with  valvular  diseases  of  the  heart;  the  mucous 
membrane  and  the  underlying  structures  are  swollen,  the  surface 
is  deep  re<l  in  color,  and  an  increase  in  secretion  is  seen.  Petechial 
hemorrhaKes  occur  in  severe  infianimations,  in  those  sufferiiig  from 
severe  systemic  infections  and  in  instances  of  hemorrhagic  diathesis. 

Inflammation.  —  Bronchitis,  while  often  universal,  is  not  neces- 
sarily so;  in  the  larger  tubes  it  is  generally  associate*!  with  tracheitis, 
in  the  terminal  bronchioles  with  lobular  pneumonia.  It  arises  hy 
extension  from  the  trachea  in  all  or  any  of  the  conditions  in  which 
tracheitis  is  found,  including  the  infective  fevers,  while  it  constantly 
accompanies  emphysema,  bronchiectasis,  and  pneumonia,  and  is  almost 
certain  to  accompany  the  (!evelopment  of  the  passive  congestion  in 
heart  disease.  The  i)roiichi  are  re(hlened,  coveret!  with  a  mucoid  or 
a  purulent  secretion,  in  which  latter  case  scpieezing  the  lung  tissue 
leads  to  the  expression  of  tiny  drops  of  mucoi)Us  from  the  openinjis  of 
the  bronchioles. 

Acute  Bronchitis.-  In  the  sim|)lc  catanhal  form  hypersecretion  is  ii 
fre(iuent,  though  not  a  necessary  characteristic,  for  a  small  amount 
of  sticky  mucus  may  be  seen  in  cases  of  so-calltn!  "dry  catarrh."  In 
cases  where  secretion  is  abundant  it  is  likely  soon  to  become  ijurii- 
lent,  and  in  cases  of  passive  congestion,  especially  where  there  is 
(cdcma,  there  may  be  a  very  abundant,  thin,  watery  secretion,  the 
so-c'illed  "serous  catarrh." 

Pundntt  liriin(liHin.—\i\  cas<-s  that  do  not  (juickly  recover,  this  may 
l)e  a  disease  of  serious  import,  for  the  walls  become  infected  with 
putrefactive  organisms,  and  the  purulent  secretion  may  become  m- 
tenselv  fetid,  and  the  likelih I  of  destruction  of  the  bronchial  wall 


i:i^  !S-':V-Vri 


Bfl 


THE  BROSCHI 


445 


iiiiil  coiistHiuent  abscess,  is  iiicreaswl.  Tliis  is  th«'  KM-allwl  putrid  f)r 
gangrenous  bronchitis. 

Ill  fibrinous  bronchitis  tlu>r(>  may  he  (ies(|uamati<)ii  of  the  epithdiiini, 
(•(iii>;estion,  «e<letna,  and  infiltration  of  the  suhmucosa,  while  on  the  free 
>iirfa(;e  there  is  an  alumdant  exutlate,  fibrinous  ami  richly  cellular, 
wliicli  in  sections  of  the  lunj;  is  often  seen  to  fill  the  bronclms  completely. 
Such  a  microscoi)ic  picture  <loes  not  necessarily  moan  that  the  bronchus 
i^  impervious  to  air.  It  is  worthy  of  note  that  in  bronchial  asthma,  a 
cltar.  glassy,  \  iscid  secr«'tion  is  expectorated  in  "pearls,"  which  are  fmind 
(111  closer  examination  to  be  capable  of  extension  into  a  long  spiral 
iiroiind  a  central  threa<l;  as  the  tube  ca.'t  is  a  "cast"  of  the  urinary 
tiit)iile,  so  the  "Curschmann's  spiral"  is  a  cast  oi'  the  hn>nchiole. 
Neither  this,  nor  the  "Charcot-I^yden'  crystal,  is  pathognomcmic  of 
iistlniiii. 

.\s  in  the  larynx  an<l  trachea,  membranous  bronchitis  is  usually,  but 
not  always,  the  result  of  infection  by  the  diphtheria  bacillus. 

Flu.  221 


ltl>inM»us  I>n>h<iiiti8      CaRt  of  I'xport  -rated  fihrinoiiH  exudalo.      (Pathological  MuMCuiii, 
>"«  CIill  Vniv'THity  ) 

Chronic  Bronchitis. — The  point  of  most  im|)ortance  in  whicli  this 
ilitiVrs  from  the  acute  form  is  that  it  tends  to  be  pnMluctiv,  the  wall 
liiiiiic  dtfiiiitely  hypertrophic;  even  the  mucosa  may  l)e  rough  and 
piilypoid,  due  to  the  irregular  contractions  of  areas  of  fibrosis.  Vet 
in  M  very  long-continued  inflammation,  the  products  may  bo  absorbed, 
;inil  tlif  nnicous  glands,  muscles,  and  cartilages  atrophy,  s»)  that  the 
l>r(.!i(liii>  may  finally  be  dilated  and  thin-walled.  The  specific  forms 
"1  lin.iu  ii';t;s  scarcely  differ  from  traciheitis  and  laryngitis  from  the  same 
(iiiiscs     tiilKTciilosis.  syphilis,  etc. — unless  it  be  in  their  greater  rarity. 

Foreign  Bodies,  etc.  -A  foreign  body,  inhaled,  is  likely  to  fall  into 
'Ik  riglit  bronchus,  because  il  is  larger  and  more  vertically  .situated 
'liaii  ih'-  left;  if  it  completv'ly  obstruct  the  bronchus,  collapse  of  the 


■■«;■■■•■' 


-7  JW 


44r. 


THE  RESPIUATORY  SYSTEM 


■■««r:. 


-, 

Lt.. 

part  of  the  lung  suppliiHl  will  folluw  if  tlu  b«xly  inhaled  be  septic, 
or  if  the  trauma  he  coiisiderahle,  a  putrid  hronthitis  and  abscess  may 
l)C  quickly  set  up;  ut  the  best,  there  is  likely  to  l)e  loealiztnl  inflanimntinn 
and  ultimately  a  fibroid  induration  BrouchoUths.  masses  of  in>pissated 
secretion  in  whieli  lime  salts  lia\e  f>ecn  deposite<l,  are  occasionally 
found,  esiMH-ially  in  bronchiectasis. 

ProgressiTe  Tissue  Ch»n«e8.-'rhe  hypertrophy  which  uiay  result 
from  chronic  bronchitis  seems  to  form  a  starting  point  for  many  kinds 
of  tumors,  such  as  chondroma,  osteoma,  myxoma,  lipoma,  and  adenoma, 
which  have  been  observed  to  occur  relatively  frequently  in  bronchi- 
ectasis. ()i:  the  whole,  however,  beniRU  new  growths  of  the  bronchus 
are  very  rare.  Hoth  carcinoma  and  sarcoma  of  th-  bronchi  o<  ( ur  as 
primary  growths,  although  infretpiently.  (  areful  ludy  shows  that, 
following  chronic  inflammation,  the  bronchial  mucosa  is  liable  to  present 
areas  of  metoplasia  from  cylindrical  into  squamous  epithelium,  and  some 
of  the  cancerous  growths  -how  epithcliomatous  tendencies.  Secondary 
growths  of  both  orders  are  often  seen. 

Alterations  in  the  Lumen.  -  Perforation.-  Perforation  of  tin-  bronchus 
may  arise  from  foreign  body  or  from  inflammation,  while  caseation 
of  lymph  nodes,  carcinoma  of  the  (esophagus,  abscess  or  aneurysm 
may  break  in  from  the  outside. 

Occlusion.--  Foreign  bodies,  masses  of  secretion,  moist  or  dry  (broncho- 
liths),  intrabronchial  tumors,  or  the  contraction  following  a  syphilitic 
ulceration  may  occl.ule  the  bronchus;  or  from  without,  the  pressure 
of  enlarged  lymph  nodes,  of  mediastiiml  tumors,  or  aneurysms  may 
bring  about  a  similar  ett'ect.  If  tlic  obstruction  be  complete,  the  air 
in  that  part  (>(  the  iiing  is  ^Tadually  absorbed  by  the  blood  and 
collapse  follow:  ,  wlureas,  if  it  be  only  partial,  the  alveoli  are  dilated, 
and  emphysema  ensues. 

Bronchiectasis. — This  is  a  diseased  state  in  which  the  bronchi  arc 
dilated  and  often  <listortcd,  by  reason  of  increased  intrabronchial 
pressure  combined  with  weakness  of  the  walls  of  the  tubes;  the  resulting 
enlargement  may  be  single  or  multiple,  local  or  generalized,  and  accord- 
ing to  its  form  oiif  recogiii/es  saccular,  cylindrical,  fusiform,  and  yaricose 
dilatatitms.  The  wall  m.iv  l)c  atrophic  or  hypertrophic,  and  within  the 
lunun  i.>  acc.i  to  be  encircied  l)y  ridges,  which  represent  the  less  yielding 
muscular  and  elastic  parts  of  the  wall,  while  the  more  yielding  con- 
nective tissue  has  given  way.  'J'he  hypertrophic  form  is  found  mosi 
often  in  a  highly  fil)r')id  lung  in  which  an  irregular,  heightened  pressure 
is  found  as  a  result  of  some  parts  of  the  lung  being  cut  off  entirely 
from  tht  ir  supply  of  air  and  the  j)re?sure  in  other  parts  being  icrrc- 
spoudingly  higher  than  normal;  pleural  adhesions,  too,  may  be  so 
situated  as  to  pull  upon  a  bmnehus  in  two  opposite  directions  at  tho 
same  ti:ne. 

Tiii- .  \istenci  of  a  bronchiectasis  is  usually  evident  to  the  naked  >  ye; 
even  if  the  dil.'tations  arc  not  of  \ cry  great  size,  it  may  be  possible  to 
trace  the  tub.-  .ilm()st  I )  the  periphery  of  the  lung,  and  their  mucosa  iS 


m\j;  ^MX^i' 


TllK  Luxas 


147 


almost  certain  to  show  cvitlt-nces  of  tli«  arcompanyirif;  hronchitis,  while 
cDJlapse,  compression,  cavitation,  or  itiduration  of  the  neighboring 
liiiig  tissue  may  l>e  visible. 


THE  LUNOS 

AbnomutlitieB. — The  anomalies  of  the  lungs  are  unimportant;  vari- 
ations in  the  lobulation,  esiwcially  of  the  right  lung,  are  often  seen. 

Circulatory  DiBturbances.-IEdema.  Where  death  has  been  slow, 
tlicro  is  almost  certainly  to  be  found  some  (edetna  of  the  lungs,  which 
arises  from  the  laxity  of  the  vessels  of  a  failing  circulatory  system 
assisteil  by  the  toxic  or  infective  manifestations  that  we  have  pre- 
viousl.v  referre<i  to  as  likely  to  occur  in  the  last  hours  of  life.  The  lung 
is  heavi'-r  and  firmer  than  normal,  and  on  scjueezing  it,  a  thin,  watery 
Huid  exudes.  In  this  fluid  there  are  no  constant  cellular  elements, 
but  accidental  blood  corpuscles,  leukocytes,  or  lining  alveolar  cells  may 
be  seen.    This  is  the  so-calh»d  afonal  oedema. 

Congestive  (Edema  is  found  accompanying  passive  hyperemia,  the 
jHistcrior  (dependent)  parts  of  the  lungs  being  most  affecteil;  the  fluid, 
from  long  continuance  of  the  congestion  may  be  mixed  with  blood  or 

ill  Kid  pigment.  Inflammatory  oedema  ms^y  be  found  in  the  early  stage 
of  pneumonia,  in  the  vicinity  of  pneumonic  areas,  and  sometimes  in 
eases  of  bacteriemia;  cellular  elements  are  often  present,  and  the  fluid  is 
more  albuminous  than  in  the  previous  forms.  The  most  interesting, 
and  the  least  understood  form  is  acute  fulminatinK  oedema,  which  may 
lome  on  very  suddenly  with  dyspna'a  and  the  free  expectoration  of 
iarire  (juantities  of  thin,  watery  sputum;  it  seems  to  be  the  result  of  a 
.^ndden  rise  of  pulmonic  blood  pressure,  and  is  associated  with  aortitis 
i;nd  other  forms  of  arteriosclerosis.  Experimentally,  the  injection  of 
adrt'iiin  sometimes  causes  it  in  animals.  Microscopically,  (edema  of  the 
linij;s  is  not  shown  by  any  change  of  the  tissue,  although  if  the  fluid 
lie  strongly  albuminous,  the  coagulated  albumin  may  be  seen  as  a 
uniform  structureless  shadow  in  the  alveoli. 

Hyperemia.  Hyperemia  or  passive  congestion  of  the  lung  arises  when 
tlnTc  is  obstruction  to  free  outflow  of  blood  fnmi  the  lungs,  or  when 
tlnTc  is  deficient  heart  power;  in  many  cases,  respiratory  movomen*  is 
weak,  and  there  is  damaged  heart  muscle,  in  which  case  the  combination 
i~  It  sponsible.  The  blood  is  allowed  to  remain  in  the  lesser  circulation 
longer  than  it  shouhl  normally;  this  stagnation,  or  slow  circulation, 
i-  most  marked  in  the  dejjcndent  parts  of  the  lungs,  the  posterior 
'i.il\  IS  of  both  the  lobes  in  the  recumbent,  the  lower  halves  of  the  lower 
l'il.(>  ill  tjiosf  who  sit;  this  postural  type  is  called  hypostatic  congestion. 
')l)strii(ti(m  to  the  outflow  fnmi  the  lungs  iray  be  due  directly  to  a 
\al\iilar  lesion,  such  as  a  stenosis  of  the  mitral  valve,  but  more  often 

'  is  due  to  an  'inemptied  state  of  the  left  auricle,  from  whatever  cause. 
'\  1     <\  <  i  Uie  heart  is  incc.mpetent,  it  is  to  be  remembered  that  the  step 
'  s  incomplete  empt;y  ing  of  the  left  auricle  is  passive  congestion 


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448 


THK  RKSI'IHATORY  SYSTEM 


■'«    i 
,    1 


of  the  lungs.  The  coiim'sted  luiif;  is  eiilarjied,  firm,  less  elastic  than 
usual,  and  of  a  dark  red  orpuri)le  color;  with  lonj;  continuance,  a  fibrosis 
of  the  lung  occurs,  and  from  the  dark  color  and  the  increased  firmness, 
this  has  been  called  cyanotic  induration.  Where  much  bloo*!  is  broken 
down  in  the  course  of  a  long-continued  congestion,  the  pigment  stains 
the  tissues  and  the  predominant  rusty  color  I'^ads  to  the  term  "brown 
induration"  being  employed.  In  such  a  lung,  there  are  seen  in  the 
alveoli,  or  in  the  fluid  expressed  from  the  scfueezed  lung,  large,  flat 
cells,  generally  circular,  laden  with  brown  pigment  graiuiles — the  "cells 
of  heart  failure"  or  "cardiac"  cells,  which  are  the  desquamated  cells 
that  in  tin  ir  lifetime  lined  the  alveoli.  The  microscopic  appearance 
of  the  congested  lung  is  readily  interpreted;  the  vessels  in  the  inter- 
alveolar  septa  are  congested,  tortU(»us  and  varicose,  and  seem  to  jut 
into  the  alveoli  in  a  succession  of  bead-like  projections.  Blood  cor- 
puscles are  apt  to  apjjcar  in  the  alveoli.  With  this,  there  is  an  increase 
of  the  fibrous  tissi\'  of  the  interalveolar  septa,  which  are  often  richly 
cellular,  the  increase  being  due  to  the  numbers  of  fibroblasts.  Very 
characteristic  are  the  "cardiac"  cells  mentioned  above,  and  in  long- 
standing cases  the  j)igment  is  not  confined  to  these  but  is  seen  in  the 
septa  themselves. 

Hemonhage.-  Blood  free  in  the  lung  is  usually  from  the  pulmonary 
\essels,  but  it  may  be  aspirated  from  the  nose  or  mouth  or  may  come  in 
from  an  aneurysm  external  to  the  lung;  one  of  us  (McC.)  has  described 
an  aortic  aneurysm  exjianding  in  the  upper  h)be  of  the  lung.  This, 
however,  is  a  nwv  oc«'urrence;  the  common  mode  of  production  of 
pulmonary  hemorrhage  is  by  erosion  of  a  vessel  in  tuberculous  or  other 
ulceration  or  its  rupture  by  trauma.  In  tu!)erculous  cavitation  the 
blood  vessels  being  very  resistant  may  be  left  ])rojecting  into  a  cavity 
as  a  loop  or  even  crossing  from  side  to  side.  Such  a  vessel  is  unsuj)- 
ported,  and  its  wall  being  degenerated  a  rupture  may  ensue,  or  an 
aneurysmal  dilatation  which  later  rujjtures.  Death  does  not  so  often 
result  from  a  single  large  hemorrhage  as  from  the  effect  of  repeated 
hemorrhages. 

Infarct.  An  infarct  is  the  area  in  which  a  hemorrhage  occurs  as  a 
result  of  the  blood  suppl\  to  it  being  cut  ort'  by  a  clot  lodged  in  the 
vessel  supplying  it.  Thetyi)ical  infarct  is  cone-shaped,  sharply  defined, 
the  base  of  the  cone  usually  situated  at  the  pleural  surface,  the  apex 
imiermost  at  the  point  where  the  clot  is  lodged;  it  is  elevated  above 
the  cut  surface  of  the  lung,  is  dark  red  or  purplish,  and  firm.  The 
pleural  surface  is  at  first  smooth,  but  becomes  roughened  by  the  fibrinous 
deposit  that  results  from  reactive  infianmiation.  The  edges  are  usually 
sharj),  and  with  the  lapse  of  time  may  become  gray  from  fibrin  and 
leukocytes,  while  the  centre  may  (rarely)  soften.  Microscopically,  the 
air  sacs  arc  distended  with  blood  corpuscles,  and  the  relation  of  'he 
.septa  to  one  another  is  unchanged;  the  nuclei  of  the  tissue  cells  in;iy 
stain  i)oorl\ .  At  the  jieriphery  of  the  infarctous  area  leukocytes  ire 
usualh'  abundant. 


THE  uwas 


449 


Witli  the  lapse  of  tinu"  the  iiitiirct  tends  to  he  absorbed;  with  the 
lircakiiif;  up  of  the  corpuscles  and  the  setting  free  of  pigment  the  alveolar 
>p;i((s  begin  to  be  reestablished,  and  circulation  restored.  Should 
infection  occur,  abscess  will  follow,  but  necrosis  and  cicatrization  are 
I II  it  common  in  the  lung. 

Ari-ing  as  infarcts  do,  in  val  iilar  diseases  of  the  heart,  it  may 
lie  tliiit  the  capillary  walls  are  degenerated,  and  rupture  is  brought 
iilioiit  by  the  force  of  the  collateral 
circulation  acting  on  the  capillaries 
tliiit  arc  full  (from  the  bronchial 
arteries).  It  is  still  (lebated  whether 
the  hemorrhage  occurs  per  rhexin 
(ir  jivr  (liojH'desin. 

Embolism. — Although  this  is  dealt 
with  in  connection  with  the  vascular 
>ystein,  it  may  be  pointed  out  that 
fiit  embolism  occurs  in  the  lungs  in 
the  ease  of  fracture  of  a  long  bone, 
vviiere  fat  is  picked  up  by  the  iilood 
fr.iin  the  marrow;  in  fresh  tissue  the 
l;it  ^'Idbiiles  may  be  seen  and  stained 
in  the  vessels.  Particles  of  fibrin 
111-  e\t"ii  large  thrombi  may  be  de- 
iMched  from  the  systemic  veins, 
iiiid,  passing  through  the  heart,  may 
Indue  in  the  lung;  if  a  large  ves.sel 
lie  hldcked,  instant  death  may  be 
tlie  result. 

IHnidSfd  States  Due  to  Disturb- 
innf  (if  the  Respirator}!  Funetion. — 
Atelectasis. — This  is  the  state  in  which  the  air  sacs  are  partially  or  com- 
pletely mulistended  by  air.  ("oinplete  airlessness  is  called  apneamatosis. 
The  true  atelectatic  state  is  that  in  which  the  limgs  have  never 
lurn  distended;  in  it  the  bronchi  are  lying  in  folds  longitudinally, 
and  the  alveolar  walls  are  in  contact  with  each  other,  to  be  thrown 
a|iiirt  and  distended  with  the  first  breath  inspired.  A  persistence  of 
I  lie  foial  state,  with  a  failure  of  proper  expansion,  may  be  found 
1"  debilitated  and  premature  children,  especially  those  with  such  a 
■ie\elii])mental  defect  as  hypoplasia  of  the  lung  or  a  diaphragmatic 
l'ernia;or  with  bronchial  obstruction  by  foreign  body,  by  meconium, 
'1  liy  secretion  or  by  compression  of  the  thorax.  Not  oidy  in  infants 
'lies  atelectasis  occur,  but  in  weakly  or  moributid  adults  it  may 
.ii'Ne. 

\Mien  there  is  a  mechanical  cause  allowing  the  egress  but  not  the 
i-Tess  of  air,  the  respiratory  act  is  not  of  itself  suflicient  to  produce  a 
'ite  of  airlessness,  !)ut  the  resitbie  of  air  that  cannot  be  expelled  is 

A\ly  absorbeil  l)y  the  blood  until  the  alveolus,  being  empty,  collap.ses 

29 


I  ^  

St'rti  n  from  an  infarct  of  the  lung,  show- 
ing cPDtrnl  portion  Tlie  alveolar  walls  stain 
poorly;  the  alve  jli  are  difliendcd  with  blood 
in  which  are  oei  usional  pigment-holding  cells, 
staining  deeply. 


4r)0 


THE  RESPIRATORY  SYSTEM 


i 

ii 

^^, 

completely,  with  what  maybe  resarded  as  a  compensatory  dilatation 
and  congestion  of  the  vessels  of  the  alveolar  walls. 

External  pressure  upon  the  lung  or  a  part  of  it  induces  a  compression 
atelectasis.  Fluid  or  air  in  the  pleural  cavity,  an  elevate.l  diaphragm 
a  mediastinal  tumor,  enlargement  of  the  heart  or  pericardium,  thick' 
enmg  of  the  pleura  or  distortion  of  the  spine  may  all  he  effective  not 
only  by  reason  of  direct  pressure  but  also  by  indirect  interference 
with  proper  respiration. 

When  the  whole  lung  is  atelectatic  it  lies  high  up  in  the  thorax 
close  to  the  spinal  column,  possesses  the  bulk  of  a  moderate  sized  adult 
hst,  and  IS  brownish  red  in  color,  or  if  anemic,  is  gray.  From  its  resem- 
blance to  flesh  It  IS  sometimes  called  "camified."  It  does  not  crepitate 
and  It  sinks  in  water;  if  squeezed  below  the  surface  of  the  water  a  few 
bubbles  may  be  expressed,  chiefly  from  the  bronchioles.  If  onlv  ,■ 
part  of  the  lung  be  atelectatic,  the  surface  of  that  part  is  smooth,  dark 
and  depressed  below  tiie  surface  of  the  rest  of  the  organ 

In  the  f(rtal  state,  the  lining  cells  of  the  air  sacs  are  polvhedral  or 
rounded,  and  project  from  the  walls;  with  complete  expansion  <.f  the 
ling  they  become  flattene.1,  and  with  a  subsequent  acquirement  of 
tne  atelectatic  state,  they  once  more  assume  their  former  shape 

Emphysema.-- The  term  interstitial  emphysema  describes  the  state  in 
which  the  tissues  of  the  body  at  large  or  the  connective  tissues  of  the 
lung  are  inhltrated  with  air,  while  emphysema,  pure  and  simple,  denotes 
the  oyerdistensioi,  of  the  air  sacs.  When  this  is  generalized,  there  are 
certain  w«^l-marked  physical  ppculiarities  in  the  thorax.  The  accessory 
musclc>s  of  respiration  are  well  developed,  the  neck  appears  short  and 
tluck  the  chest  IS  enlarged,  .-specially  in  the  anteroposterior  direction, 
so  as  to  be  barrel-shaped,  whilr  the  abdomen  is  relativelv  sunken.  r.H.n 
opening  the  thorax  the  lungs  arc  ^•oluminous.  relati^•elv  of  light  weight, 
an.l  do  not  collapse.  The  tissue  is  inelastic,  less  crepitant  than  normal, 
keeps  the  imprint  of  the  fingers  and  feels  like  "a  bag  of  feathers." 
On  the  surface  the  pigmentation  is  slight,  the  surface  pale,  and  at 
times  tlie  individual  air  sacs  can  be  seen  with  the  naked  eve  like  little 
vesicles.  In  a.lvanced  cases,  especially  at  the  edges  of  the  lungs. 
individual  sacs  may  become  of  great  size,  giving  the  lung  a  bullous 
appearance  (bullous  emphysema). 

^Microscopically,  as  seen  in  Fig.  217,  p.  432,  in  a  case  of  emphv.se.na 
there  is  marked  atrophy  of  the  alveolar  walls,  and  manv  of  them  ar,- 
ruptured;  several  alveoli  are  thus  thrown  into  one,  and"  the  resulting 
sac  takes  a  shape  approximating  to  the  circle.  In  the  thinning-out  and 
rupture  of  the  walls  the  blood  vessels  necessarily  are  flattened,  thiniuHi 
out,  and  many  are  thus  ol.  terated;  the  diminution  of  space  that  occurs 
in  the  remaining  vessels  due  to  pressure  throws  increased  work  upon  the 
heart  and  the  right  ventricle  distends  and  hvpertrophies. 

Inflammation.-  Pnemnonia.  — Here  consideration  is  given  to  the 
pathological  aspect  of  an  inflammation  of  the  lung  itself—a  pneumonia 
or  pneumonitis— and  not  to  the  manifestations  elsewhere  that  arc  a 


THE  LUNGS 


451 


|)iirt  of  the  disease  that  is  termed  by  the  clinician  pneumonia.     Yet  we 
niiiy  not,  for  a  moment,  disregard  the  fact  that  the  reader  finds  his 
interest  chiefly  in  the  clinical  manifestations  of  the  disease.     It  is 
necessary  that  one  see,  at  the  outset,  that  an  inflammation  of  the 
interstitial  tissue  of  the  lung  is  just  as  truly  a  pneumonitis  as  an  inflam- 
niiition  of  the  air  sacs,  though  by  no  means  so  common.     Even  more 
iini)ortant  is  it  for  him  to  recognize  that,  numerous  as  the  causative 
iifl'-'its  are,  and  diverse  as  are  the  modes  of  infection,  yet  the  air  sacs 
resiMHid  to  irritations  of  all  sorts  in  much  the  same  way.    Just  as  was 
said  in  the  general  discussion  of  inflammation,  the  process  may  vary 
in  sixed,  in  intensity,  and  now  this  feature  and  now  that  other  may  be 
I)rnniinent,  but  at  the  bottom  of  them  all  lie  the  same  fundamental 
(Kcurrences;  the  blood  vessels  become  congested,  there  is  an  outpouring 
of  >erum  and  a  diapedesis  of  leukocytes,  a  formation  of  fibrin,  a  contem- 
Ijoraneous  killing  or  injuring  of  the  cells  of  the  part,  especially  those  that 
line  the  air  sac,  and  e\en  a  multiplication  of  those  cells  that  are  mildly 
irritated-  all  this  occurring  in  the  dosed-in  space  of  the  air  sac,  so  that 
the  pruduets  of  the  inflammatory  process  fill  the  air  sac  to  the  exclusion 
of  air,  and  the  disposal  of  such  product.-,  constitutes  a  step  to  be  per- 
formed i)y  the  body  in  the  process  of  healing,  over  and  above  what  has 
to  !)(■  (lone  in  a  case  of  inflammation  on  a  surface. 

Ahnost  all  the  known  pathogenic  organisms  have  the  power  of 
eansmg  pneumonia;  the  Fninkel-Weichsclbaum  diplococcus  of  pneu- 
monia, Kritdlander's  bacillus  of  pneumonia,  the  Streptococcus  pvogenes, 
the  Staphylococcus  albus  and  aureus,  B.  tuberculosis,  B.  tvphi  "abdomi- 
HiilK,  15.  eoli,  B.  influcnzie,  B.  pestis,  B.  anthracis,  and  B.  diphtheria' 

■  iKlnde  nearly  all.  While  each  of  these  is  able  unaided  to  produce 
the  disease,  it  actually  happens  very  often  that  the  infecti(m  is  mixed. 

■  |S  to  the  maiuier  of  infection  e'  ryone  of  these  bacilli  can  reach 
th<'  Inng  either  by  the  bronchial  tract  (aerogenic  pneumonia)  or  by 
the  blood  or  lymph  (hematogenic,  lymphogemc  pneumonia).  As  to  what 
"liiiieal  type  of  <lisease  will  be  set  up  by  a  special  organism,  we  can 
^Mv  little  more  than  that  there  is  no  unvarying  rule;  the  pneumococcus 
■I  tMip  most  often  a  lobar  pneumonia,  bul  may  cause  the  lobular  form, 
^^lllle  there  seems  no  reason  to  suppose  that  any  of  these  organisms 
i>  iiiiahie  to  cause  a  lobar  pneumonia,  Be  this  as  it  mav,  lobar  pneu- 
'ii"ina  111  the  e! laical  acceptation  of  the  term,  is  a  very  different  kind 
"  <ii-efise  from  any  other  form  of  pneumonia;  it  is  essentiallv  a  general 
I'  ■""  infection  with  a  local  manifestation  in  the  lung;  histologically 
I  III-  local  manifestation  has  close  resemblance  to  other  pulmonary 
iiiflammations. 

TiM'se  pulmonary  infections  are  due,  it  will  be  seen,  to  bacteria,  many 
"I  ^\lii(li  are  iiabitual  residents  of  the  body;  under  what  conditions  do 
t.ie>e  haeteria  gain  power  to  attack  the  tissues?  I'erhaps  the  body  is 
■ittaeked  at  a  moment  of  chilling  or  at  a  time  when  resistance  is  in  some 
•  -<r  way  lowvred,  or  the  bacte.ia  become  increasinglv  virulent;  the 
!^"re  tact  that  a  particular  lobe  is  attacked  seems  to  indicate  that  this 


4r)2 


rilK   liKSI'IHATORY   SYSTEM 


IS  a  |)la(('  (it  Ifiist  rcsistaii(«'.  Ldliar  piiniiiioiiia  is  that  form  in  wliicli  a 
part  (.f  a  lohc,  a  whole  lol),.  „r  several  lol.es  are  atlVcte.l;  all  other  forms 
of  pneumonia  are  of  th.-  lol.iilar  type  in  which  the  unit  affected  is  the 
lobule.  The  names  hy  which  the  ditferent  forms  are  characterized  are 
many,  some  haseil  u|)on  the  mode  of  conveyance  of  the  causative  ajjent, 
some  upon  the  anaton)ical  character  of  the  lesion.  .Vmouf;  the  clinical 
types  of  lobular  i)ueuinonia  are  bronchopneumonia,  in  which  the  infection 

ivels  down  one  or  many  bronchi,  thus  ol.tainiuK  a  lobular  distribution: 
mUiary  pneumonia,  in  which  the  blood  stream  infects  multi|)le  foci 
at  once;  septic  and  metastatic  pneumonia,  in  which  the  hmjj  is  aflVcted 
in  multiple  areas  as  an  expression  of  a  widespread  bacteriemia;  hypo- 
static pneumonia,  in  which  the  lobules  attacked  an-  n.cessarily  in  areas 
that  are  already  the  subjects  of  passive  conj;estion,  and  terminal  pneu- 
monia in  w  hich  the  lunj;  is  attacked  because  it,  in  conunon  with  the  rest 
of  the  body  is  in  a  low  (ante  mortem)  state  of  resistance.  All  these 
have  a  lobular  distribution  of  the  infe<tion.  \\  hile  the  character  of  the 
exudate  may  sometimes  enable  us  to  decide  what  is  the  infection,  our 
knowledfie  of  the  process  of  iuHainmation  will  render  us  cavitious  as  to 
depending  absolutely  ui)on  this,  and  the  smea."  and  the  culture  are 
safer  means  of  ditferentiaticni. 

Acute  Lobar  Pneumonia.-  The  well-known  division  of  the  course  of 
theciisease  into  four  stages  was  never  accurate  and  has  outlived  its 
usefulness.  It  is  dear  enoufih  that  con^^estion  is  f,)llowed  by  consolidii- 
tion;  the  lunf;s  seen  at  autopsy  fre(|uently  present  an  appearance  well 
described  in  the  term  "red  hei)atization,"  often  show  the  state  of 
pray  hepatization,  and  very  often  are  seen  in  a  moist,  jjray  state  well 
described  by  the  term  purulent  infiltration. 

The  period  of  congestion  or  engorgement  is  midoubtedly  brief,  rarely 
seen  l)y  the  patholojiist  and  often  referred  to  by  careless  clinicians  us 
"congestion  of  the  luii<;s,"  '•threateiiinjr  pneumonia,"  o  some  such 
term.  What  the  clinician  can  ol)serv<'  at  tiiis  stape  is  \m  rely  the  moist 
state  of  the  bronchi  and  bronchioles;  considering  the  frequency  of 
bronchitis,  all  the  preliminary  sij;ns  of  the  onset  of  jjueumonia  are 
retpiired  before  he  may  make  even  a  likely  j^uess  as  to  whether  piuii- 
moiiia  is  or  is  not  to  supervene.  The  lunj;  at  such  a  time  is  reddened, 
distinctly  (edematous;  if  seen  at  autopsy  it  oozes  abundant  blood  on 
.section  and  is  curiously  brittle.  This  (juickly  jrives  place  to  consoiid.i- 
tion,  in  which  the  Iun>;  i)ecomes  heavy,  swolleiv  firm,  pits  on  pressure, 
and  is  more  friable  than  normal  It  is  intensely  red.  owing  to  vasciihir 
hyi)eremia  rather  than  to  the  jm-sence  of  red  corpuscles  in  the  exii(i;iic, 
and  the  fluid  scraped  off  the  cut  surface  witn  a  knife  is  definitely  tiirl-l. 
and  ')lood-staine(l.  Microxopically.  the  capillaries  are  congested,  liic 
lining  epithelium  of  the  air  sacs  is  swollen,  often  desquamated.  m\A 
fibrin  and  leukocytes  are  i)rescnt,  the  fibrin  threads  mak  ,ig  a  conipli  te 
mesh  ill  the  air  sac  just  as  a  blood-clot  adheres  to  the  sides  of  a  gln-s 
vessel.  lu-d  corpuscles  are  im-seni.  rioin  the  red  solid  a|)pearaiicr  ..i' 
the  tissue  in  this  state,  it  was  likened  to  liver,  and  the  term  hepatization 


THE  LVSGS 


4.53 


"iKir  iiiii'imioniu  (uruy  lic|M(izalimi).     The  IciwiT  iohc  is  involved      (Pathological  Museun 
MiGill  University.) 


iKi.  a24 


sXn^ 


!•'•-.  ■>t-nto  Inter  pmnmv.nis,  =^tr,K,.  „f  f..,l  hvp::iizati:m.  The  rcntro  „i  ih,-  u.ieloscpi.-  fiei,!  ia 
>\><-'l  by  an  air  vosick-  cnntainiiig  a  mass  uf  exudate  composed  of  a  network  ..f  Bbrin,  red  blood 
'.  iin.l  a  few  leukocytes.    (Hare.) 


wm^^mmmim 


454 


THE  RESPIRATORY  SYSTEM 


Kui.  ■^25 


iippliod  to  it.  To  iiiKierstiind  properly  how  this  changes  to  the  so-calle«i 
gray  hepattiation,  a  consideration  of  the  microscopic  appearance  is  neces- 
sary. After  tlie  hipse  of  a  Uf  '-  time  tlie  fibrin  tiireads  begin  to  break 
np  under  the  action  of  enzviues,  and  just  as  the  blood  clot  shrinks 
away  from  the  sides  of  *.lic  j;luss  vessel,  so  the  exu<late  or  clot  shrinks 
from  the  sides  of  the  air  sac  and  microscopicaily  a  clear  zone  (actually 
filled  with  serum)  ai)pears  around  the  exudate;  the  fibrin  is  now  being 
digested,  dead  cells  are  being  <lisii!tegrated.  and  the  "scavenging" 
effect  of  leukocytes  and  proliferated  air  sac  a-lls  becomes  apparent; 
leukocytes  are  now  present  in  so  great  numbers  that  the  tissue  takes 
the  ch'    uteristic  color  of  lymph  tissue — gray;  disintegration  of  the 

exudate  proceeds,  until  the  air  sac 
contents  become  thinner  and  thin- 
ner, until  there  remains  only 
ly  npli,  which  is  absorbed,  and 
air  Mice  more  enters  the  air  sac. 
Or  It  may  be  that  the  loosened 
plug  of  i)artly  disintegrated  exu- 
date is  suddenly  dislodged  by  a 
cough  into  the  bronchiole,  and 
appears  in  the  sputum,  where  we 
can  recognize  the  fibrin,  the  leuko- 
cytes, tlic  desquamated  epithe- 
lium and  the  bacteria.  This  dis- 
integrating '  tage,  with  its  num- 
erous leukocytes  is  that  of  gray 
liepatization.  The  surface  is 
granular,*.  "olor,  the  lung 

is  firm,  pr.  '  .    .-nted  by  the 

ribs,  thej,.^  ;  ■  ,o  longer  glassy 
but  duIU\l  I  a  fine  fibrinous 
exudation,  Aw  lung  is  airless, 
friable  and  sinks  in  water.  The 
cut  surface  looks  granular,  and 
scraj)ing  yields  a  fluid  no  longer 
blood  stained,  but  more  turbid  than  ever.  As  time  elapses,  the  dis- 
integrative process  goes  on,  the  lung  losing  its  firmness,  the  surface 
becoming  more  lax,  and  the  stage  of  gray  hepatization  has  definitely 
passed  into  that  of  resolution.  INIany  cases,  however,  do  not  exhibit 
this  course,  but  appear  at  the  death  of  the  patient  in  a  state  of  "puru- 
lent infiltration,"  which  ditters  from  that  just  described  as  gray  hepati- 
zation oidy  in  this—  that  the  lung  is  more  moist,  and  the  scraped  surface, 
granular  for  an  instant,  quickly  becomes  clouded  over  by  a  thin  layer 
of  fluid  pus  which  exudes  from  the  alveoli  and  bronchioles;  the  tissue  is 
even  more  friable  than  before,  because  the  alveolar  septa  have  under- 
gone a  considerable  degree  of  disintegration.  One  can  well  imagine 
that,  had  life  been  i)rolonged,  the  entire  affected  area  would  soon  have 
become  one  large  abscess. 


Section  from  a  lung  with  acute  lobar  pncumoniu 
in  the  atune  of  gray  hepatization.  All  the  filjrin 
here  has  hecn  disintegrated:  n,  deequaiiiated 
alveolar  cell;  b,  disintegrating  leukoiyte;  c. 
normal  leukocyte. 


THE  LUNGS 


455 


A^  to  the  site  of  the  pneumonic  process,  oup  own  figures  show  the 
riu'lit  side  affected  in  48  per  cent.,  the  left  in  30  per  cent.,  and  both  in 
.'.'  JUT  (lilt,  of  cases.  When  both  lungs  are  affected  it  is  common  to 
tiiiil  (MIC  I'artiier  advance<l  in  the  disease  than  the  other.  The  lower 
l(il)(s  iire  more  often  the  seat  of  the  <lisease  than  the  upper,  but  it  is 
not  iiit'r((|uent  to  find  atypical  forms  such  as  "apical,"  "central,"  ami 
"creeping"  pneumonia,  terms  which  explain  themselves. 
li  Considering  the  nature  of  the  disease,  viz.,  that  it  is  a  generalized 

infection,  it  is  to  he  expected  that  the  infection  in  the  lungs  may  be 
associated  with  inflammation  elsewhere;  pleurisy,  empyenia,  peri- 
ciinlitis,  endocarditis,  meningitis,  osteitis  and  arthritis  are  those  of 
coiiiinonest  occurrence. 

Instead  of  proceeding  to  resolution,  the  exudate  may  remain  in  the 
alveoli  and  organize  (as  might  a  clot  elsewhere),  giving  rise  to  the  rare 
instances  of  unresolved  pneumonia.  It  is  a  gotxl  clinical  rule  to  remem- 
liiT  that  this  is  one  of  the  least  common  causes  of  continuance  of  the 
l)iiruiii(inic  febrile  state,  and  he  who  keeps  the  figures  of  frequency  of 
occurrence  in  his  mind  will  wisely  dispose  of  other  possibilities,  espe- 
cially empyema,  before  coming  to  this  diagnosis.  Secondary  infection 
may  Icail  to  a  breaking  down  of  the  lung  tissue  causing  abscess  or 
piiiurcnc,  closely  related  conditiors.  Especially  if  putrid  bronchitis 
or  hronchiectasis  have  been  present,  is  gangrene  apt  to  supervene, 
the  lung  becoming  pulpy,  greenish  in  color,  and  stinking.  A  line  of 
"Icniurcation  rarely  exists,  and  irregular  cavities  with  shaggy,  necrotic 
walls  are  seen.  Even  this  may  heal  by  a  fibrosis,  the  part  of  the  lung 
allccted  finally  shrinking  to  a  dense,  indurated  mass. 

Acute  Lobular  Pneumonia.— Only  rarely  is  this  a  primary  disease, 
sa\('  ill  young  children;  it  is  usually  the  sequel  to  bronchitis" or  one  of 
the  infectious  fevers,  measles,  whooping  cough,  influenza,  or  diphtheria, 
and  the  young,  the  old,  or  the  debilitated  are  the  sufferers.  The 
ori;aiiisins  are  the  same  as  in  the  lobar  form,  but  the  pyogenic  cocci 
liavc  a  greater  tendency  to  be  concerned.  A  bronchial  inflammation 
that  lias  spread  to  the  bronchioles  is  very  certain  to  go  a  short  step 
I'artlicr  and  attack  the  air  sacs.  It  is  all  but  a  safe  statement  to  make 
iliat  the  exudate  is  more  serous  than  fibrinous,  and  a  striking  feature 
is  the  presence  of  large,  clear,  mononuclear  cells,  which  are,  in  all 
|>nil)al)ility,  the  swollen  alveolar  cells,  and  these  give  to  the  exudate  a 
'  <atarrlial"  quality. 

<  'oniing  from  the  bronchi,  this  disease  is  apt  to  attack  both  lungs, 
ilthoiigh  only  one  or  a  part  of  one  may  be  affected.  The  damaged 
liiiii;  is  congested  and  in  its  substance  are  isolated  firm  areas,  raised 
■ilii'vc  the  rest  of  the  surface,  gray,  red,  or  yellow  in  color,  and  friable 
ill  consistence.  These  scattered  areas  may  grow  larger  till  they  coalesce, 
l>iit  tluy  never  succeed  in  producing  the  uniform  solidity  of  the  lobar 
t>  ])e  of  pneumonia.  With  the  possible  exceptions  noted  above,  a  piece 
'!■ -11!  the  middle  of  one  of  these  areas  is  microscopically  iudistinguish- 
i'l'ie  irom  a  similar  piece  cut  from  the  middle  of  a  lung  in  lobar  pneu- 


M!  i|l.fll|  IMipf 


II 


456 


TIIK  RESl'IRATORY  SYSTEM 


nioiiia.  Tlu'  iiidivulual  consolidation.,  pass  throujrh  red  and  jtray  stages, 
iiiid  tlu'  sporadic  distrihiition  of  these  areas  li.is  led  to  the  hinj?  beinj; 
lii<ened  to  a  sple«'n  h»iice  the  term  "spleniiation"  (not  to  l)e  com- 
mended). Wlien  consohdation  (ucurs  and  resolves,  the  resolution  is 
apt  to  jjrogress  more  (piickly  tiian  in  lol)ar  pneumonia,  because  the 
lymi)h  and  blood  streams  arc  less  interrupted.  l)Ut  not  tlie  less  is  it  a 
serious  diseas*-.  since  it  attack>  at  a  time  of  low  vitality  or  complicates 
other  ;;r;ne  disease.  Several  of  the  difierent  forms  must  be  considered 
individually. 

Fio.  226 


Twf>  iilveoli  from  the  lun*;  in  n<'ut"  lobular  pncuniuiiia,  showinK  loowr  cell  rollortion  in  the  t^xiulatf 
Hud  aliMDce  of  fibrin:  u,  disintogrutiniE  Icukocvtos  with  gianiilar  contents;  h,  same  with  fat  globules. 

Aspiration  Pneumonia.—  A  typical  example  of  lobular  pneumonia  is 
that  known  as  inhalation  or  aspiration  pneumonia,  arising  from  the 
aspiration  of  food,  vomitus,  or  secretion  from  the  nose  and  mouth 
during  unconsciousness,  as  in  the  anesthesia  of  operations.  PVoni 
the  nature  of  the  infecting  agent  it  will  be  readily  understood  that  tlie 
tendency  to  destruction  of  the  lung  tissue,  to  abscess,  and  gangrene 
is  greater  than  usual.  It  is  a  frecpient  (  ccurrence  that  in  surgical 
cases  ending  fatally,  especially  where  vomiting  has  been  present,  tin 
trachea  and  bronchi  show  a  greeni  h  tint,  suggesting  bile-staineii 
stomach  contents,  and  this  usually  indicates  that  such  have  been 
aspirated.  Where  life  is  sufficiently  prolonged  to  allow  the  pneumonic 
process  to  supervene,  the  profuse  sputum,  often  foetid,  shows  by  the 
presence  of  elastic  tissue  that  the  lung  tissue  is  being  destroyed,  ami 
at  iiiitopsy  scattered  or  confluent  areas  of  actual  abscess  format!"!' 
will  be  found;  the  zone  ?urr(»unding  such  areas  is  likely  to  show  a 


'■•.  ;^M^B 


THE  U'xas  4i>< 

\(T.\  iiitt'iise  conRt'stion  '>eraiist'  set-ii  in  s«)  vascular  an  nrnau.  St'ptio 
liiiiuiiKinia  may  hv  caiist-il  ii)  other  ways  than  hy  inliahitiuii;  the  exten- 
-ioii  of  inflammation  from  nt  iKhhorinit  tissues,  such  as  tlie  ineiliastinnni 
(■r  tnini  snl)(liai>lira);matic  stnu-tures,  will  c-anse  it.  as  ma\  also  infec- 
tion at  the  time  of  injury  to  . ' '■  Innj;  as  in  jierforatinn  wound  of 
till'  luim  through  (he  chest  wall.  Womul  of  the  lunj;  hy  a  rii>,  where 
III)  external  womul  (\ists,  is  more  lik»'ly  to  he  followed  hy  an  unmixed 
infection  and  a  typical  pneunonia,  hecause  the  wounded  area  is  the 
liliicc  of  least  resistance  for  the  time  Ikmu)?,  and  the  infection  is  Iiema- 

tot.'fllIc. 

Metastatic  or  Embolic  Pneumonia. — This  is  allied  to  the  last  form. 
It  hapi>ens  as  a  manifestation  of  a  general  hacteriemia  in  such  dis- 
eases as  osteomyelitis,  thrombophlebitis,  arthritis,  sejjtie  endiK-arditis, 
iiiiil  erysipelas,  where  a  septic  embolus  becomes  the  point  of  origin  of 
a  laieumonic  focus.  N'-;  part  of  the  lung  is  exempt,  anil  tlie  abscesses 
can  he  felt  as  indefinite  lumps  deep  in  the  tissue  or  seen  as  yellow 
dwellings  under  the  j)leura,  varying  in  size  from  that  of  a  pinhead  to 
several  centimeters  in  diameter.  The  inflanunation  set  up  by  the 
Mptic  material  brought  by  the  embolus,  although  circumscribed,  is 
of  the  nature  of  a  localized  pneumonia,  but  it  |)roeetHls  straightway 
to  the  formation  of  abscess  or  gangrene.  Of  pneumonic  nature,  strictly 
^|)eaking,  is  also  the  effect  of  secondary  infection  in  tuberculosis,  aetino- 
iiiycosis,  or  other  primary  infection. 

Hypostatic  Pneiunonia. — A  pneumonic  infection  occurs  very  often  in 
tliii-e  who  are  debilitated,  and  because  the  posterior  parts  of  the  lungs 
are  cDiigested  and  (edematous  it  is  here  that  the  infection  strikes, 
ami  a  difi'use  catarrhal  pneumonia,  definitely  localizwl  to  this  part  of 
tlic  lung,  is  set  up;  the  general  bodily  depression  h;is  much  t  do  vith 
tlic  infection,  for  it  is  know:i  to  every  clinician  that  lnn};s  may  r.  iiiain 
conu'csted  and  (edematous  for  months  without  infect  n;  but  w'  ii  the 
individual  comes  within  a  few  hours  of  his  di  ith,  th  .o-called  urmina' 
■ifcction  takes  hold,  and  thus  it  is  that  so  man\  patients  -iitierim 
iruin  lieart  disease  die  irifh,  if  not  from  a  pneumonia. 

Chronic  Pneumonia. — ('are  is  nece.-isary  in  considering  chronii   puet*- 
iiioiiia  not  to  incluoo  the  actual  reparative  process  that  may  follow  i^ 
acute  pneumonia,  unless  an  actual  lesion  of  the  alveolar  septa  occi, 
i'lie  term  chronic  pneumonia  presupixises  that  an  irritant  is  continual 
and  progressively  at  work.    An  "unresolved  pneumonia"  is  correcily  ., 
I  lironic  pneuuionia,  and  the  infections  of  the  granulomas,  tuberculosis, 
-vpiiiiis,  actinotnycosis,  etc.,  set  up  an  inflammati(m  that  may  be  so 
ii'^iiiuated.    Chronic  pneumonias  may  be  divided  into  (1)  the  above- 
iiK'utioned  secondary  indurative  pneumonias,  (2)  pneumonokonioses,  the 
iiMases  excited  by  the  inhalation  of  various  kinds  of  dust,  and  (3) 
pleurogenetic  pneumonias,  caused  by  the  extension  inward  of  the  infec- 
tion of  a  chronic  pleurisy,  a  rare  form. 

! .  Sinindarif  Iriduralicc  Pitcumunla.     There  is  a  genera!  substitu- 
i'lii  of  fibrous  tissue  for  the  soft  lung  sul)stance,  the  pleura  and  inter- 


IW^ 


plW^l^ 


»fp^ 


4.'>8 


THE  RKSriRATORY  SYSTEM 


lobular  septa  l)eing  specially  prominent.  If  it  «Hciir  secondary  to  a 
l)rouclioi)iieunioiiiu,  the  fibrosis  roughly  follows  the  bronchial  tree. 
In  an  advanced  case,  seen  microscopically,  one  is  struck  by  the  fact, 
that,  when-as  normally  the  ffreatest  part  of  th«'  section  is  air  space,' 
and  the  least  the  walls,  here  the  greater  part  of  the  field  is  sohd  tissue 
and  th.  lesser  part  is  air  space.  The  Inng  is  heavy  and  hanl,  cuts  firmly, 
IS  grayish  in  color,  mottled  with  the  black  of  inhaled  dust.  Areas  of 
necrosis  resembling  caseation  nuiy  b<'  seen,  the  pleurae  are  thickened 
and  often  matted  together,  and  the  lung  may  be  entirely  deformed. 
Microscopically,  the  air  sacs  show  as  small  irregular  spaces  containing 
desquamated  cells  or  leukocytes,  lined  by  irregular  cubi«aj  cells,  and 


Fio.  227 


Section  from  ■  ae  of  indurstivc  pneumonia  (fibrosis  of  the  lung),  showing  the  extreme  fibroid 
thickening  of  the  alveolar  walla  ami  the  consequent  rcluction  in  sise  of  the  alveoli:  a,  alveolus  con- 
taining desquamated  cells;  ft,  somewhat  cul...  al  epithelium  lining  the  air  spaces. 

separated  from  one  another  by  wide  masses  of  fibrous  tissue.  The 
bronchi  are  irregular  in  -hape  from  pressure  or  traction.  Now  and 
then  in  the  fibrous  tissue  one  sees  large  collections  of  leukocytes  and 
young  fibroblasts  indicating  areas  of  acute  inflammation  in  the  fibrous 
tissue,  where  some  infection  still  continues  to  operate.  This  extreme 
grade  of  change  never  follows  passive  congestion;  here,  at  the  most, 
there  is  moderate  thickening  of  the  septa  and  the  alveoli  show  many 
catarrhal  cells  containing  pigment  (brown  induration). 

2.  Pnmmonokoniosis.— Little,  if  any,  inhaled  dust  reaches  the 
lungs  directly  in  the  air,  but  it  imping.-s  n;\  the  bronchial  walls,  i- 
carried  by  the  leukocytes  to  liie  peribronchial  lymph  collections  or  to 


THE  LVXGS 


450 


to  a 


the  alveolar  walls.  Wherever  it  Iniuls  it  may  -et  up  a  certain  atn'^unt 
111  itution,  tiic  more  so  if  if  particles  are  shurp-edKed,  iMicatise  these 
at  tiially  pierce  the  walls  ami  set  up  in  the  surroundinK  tissues  nodular 
reactive  jjrowths,  like  tubercles,  in  which  the  offending  pi-rticles  arc 
>liut  up.  In  a«lvaii(ed  cases  the  peribronchial  lymph  tuxks  m.-'y  l)e 
gritty,  and  particles  may  be  carried  to  ti.e  alnicminal  lymph  nwles. 
|)itr»reiit  kinds  of  dust  set  up  differ»'nt  degrees  of  irritation;  the  most 
familiar  fo  m  is  uithracosis,  from  coal  du.st,  found  in  all  adult  dwellers 
ill  (ities.  id  unimportant;  in  the  case  of  coal  miners,  however,  the 
damage  -«..ight  may  l)e  great,  and  anthracotic  tubercles  are  seen  as 
uraxisli  ..sses  of  fibros'a  with  blac'  .iics,  while  the  entire  lung  is 
soiiiewliat  infiltrated  and  is  heavy.  ;<      .ine-mason'slungCchalieotU) 

the  infiltrating  nmterial  is  grey  an  '  •-  /;  in  siderosis  particles  of  iron 
and  steel  do  the  damage,  as  is  seen  ...:ong  needle-grinders,  file-makers, 
ami  iron-workers  of  different  kinds.  The  lesions  are  not  very  different 
lrt)iii  those  of  indurative  pneumonia;  calcification  and  even  the  forma- 
tiiiii  (,f  bone  has  l)een  seen. 

Tuberculosis.-  Tulwrculosis  occurs  in  the  lungs  Iwth  as  an  acute 
ami  a  chronic  ease,  the  Bacillus  tuberculosis,  discovered  in  1882 
by  Koch,  being  the  essential  agent. 

.\s  to  tlie  mode  of  Infection,  it  may  be  stated  that  tuberculosis  is 
not  iureditary,  and  but  few  cases  of  intra-uterii<e  infection  p  e  known 
to  have  occurred.  As  to  how  the  organisms  reach  the  lung  there  has 
lirtn  much  debate;  a  reasonable  stati-ment  of  the  facts  seems  to  be  the 
t(.ll.)\viiig:  the  infection  of  the  lungs  is  nearly  always  by  the  human 
t\pe  of  organism;  the  bovine  or  the  human  form  may  be  ingested  with 
food  and  may  I  arried  by  the  lymph  stream  ultimately  to  the  thorax 
and  infect  the  1  s,  although  ihis  is  probably  an  infrequent  happening. 
Most  pi  htionar.  ..ifections  occur  by  inhalation;  of  these  very  few  are 
di't'  t,  that  ;  -,  result  from  the  bacilli  being  engrafted  upon  the  bronchial 
Mirface  .niu  setting  up  a  tuberculous  bronchitis  as  a  primary  lesion. 
Tlu'  ba(  III  are  usually  caught  in  the  mucous  membrane,  carried  to 
tin  lymi)li  nodes  where  the  infection  may  remain  (and  be  subsequently 
transferred  by  the  lymph  stream  to  the  lung),  or  they  may  be  carried 
at  once  by  the  lymph  to  the  lung.  This  transference  may  also  occur 
I'v  the  agency  of  the  blood;  and  cases  in  which  a  tuberculous  area 
HI  a  lymph  node  breaks  into  a  bronchus,  a  bronchiole  or  a  blood  vessel 
a  r  so  obvious  as  not  to  require  explanation.  This  last  is  an  unimportant 
tart,  for  it  happens  oftenest  in  advanced  cases.  Infection  by  the  skin, 
c-iHcially  by  the  bovine  form  of  the  bacillus,  happens,  though  rarely. 

\  iewed  broadly,  the  greatest  dangers  to  which  people  are  exposed 
an  u  from  the  inhalation  of  dried  sputum  or  exhalation  from  the  mouth 
:;i"l  nose.  Personal  contact  constitutes  a  grave  danger,  but  being 
i'Tocc  may  be  guarded  against;  the  infection  of  houses  and  rooms, 
iial  their  subsequent  occupation  by  those  who  are  ignorant  of  the 
':!'t,  !s  a  great  source  of  risk,  and  can  be  obviated  only  by  rigid  regula- 
!i"ii:,  compelling  notification  of  cases,  inspection,  and  disinfection  of 


4G0 


THE   RESl'IR.\T()RY  SYSTFJ.U 


Rl-I 


liouscs.  TuhiTciilous  milk,  l)iitttT,  or  im-at  is  no  nion'  serious  menace 
to  the  i)ul)lie  health  than  the  existence  of  unmarked  contaminated 
iiouses  and  rooms. 

From  the  aho\  e  considerations  it  will  he  seen  that,  accordinj;  to  the 
frenerally  accejjted  views  of  the  present  time,  i)nhnonary  tuberculosis 
instead  of  heinj;  primary  is,  in  the  majority  of  cases,  truly  secondary, 
and  of  hematogenic  or  lympiio<;enic  orijiin,  altlion^h  the  mode  of  infec- 
tion is  in  the  first  ])lace  aerial. 

Aerogenic  Tuberculosis.-  Wherever  the  hacilli,  carried  as  al)ove  stated, 
lodg.'  in  a  part  of  the  hmj;  suitable  for  their  j;ro\vth,  they  result,  accord- 
ing to  how  mnnerous  and  how  virulent  they  are,  in  a  simple  tubercle 
or  a  small  localized  are,    of  the  nature  of  a  lobular  pneumonia.    The 
site  of  i)redilection  is  just  below  the  apex  where  the  excursion  of  the 
lung  is  slifrht  and  gaseous  interchaiifie  slow,  or  otherwise,  however  ex- 
tensive their  distribution  throughout  the  lung  substance,  they  tend  to 
grow  only  in  the  region  or  regions  of  lea.st  resistance,     ("linically,  it  will 
be  recalled  that  if  a  lesion  be  found  in  one  apex  it  is  well  to  search 
carefully  the  other  a\)v\,  and  then  the  a|)ex  of  the  lower  lobe  of  the  lung 
first  involved.    At  first  the  area  involved  is  small,  gelatinous  in  appear- 
ance and  imperfectly  differentiated  from  the  surrounding  tissue.    The 
only  i)hysical  sign  available  at  tlii    time  or  even  for  some  time  to  come 
may  be  fine  rales  in  the  moist  bronchioles  of  the  region.     A  cellular 
exudate  is  thrown  into  the  alveoli,  and  the  vessels  become  blocked  by 
endothelial  proliferation,  caseation  (juickly  ensuing.     The  sharply  de- 
fined lesion  now  existent,  may  even  yet  heal,  and  be  represented  by 
a  fibrous  scar,  or  a  fibrous  mass  with  caseous  or  calcareous  centre, 
and  a  puckering  (jf  the  apex  of  the  lung.     If,  however,  the  process 
continue,  the  bacilli  are  carried  by  the  lymi)hatics  and  secondary  similar 
foci  arise  on  the  perii)hery  of  the  first.    Tlie  nodules  gradually  increase 
in  size  and  coalesce,  the  caseation  increasing  with  eciuai  pace,  until 
the  caseated  areas  in  turn  coalesce.    The  nearby  pleura  and  the  lymph 
nodes  become  likewise  infected.     IVesently  a  broncliu    is  invaded  which 
gives  outlet  to  the  broken-<lown  caseous  material,  and  bacilli  apjM'iir 
in  the   sj)utum,  contemporaneously   with    the   formation    of  the  first 
cavity.     A  gradual  jjrogression  of  infiltration  and  overgrowth  of  tissue 
in  any    or   in    all  directions   is  now   followed    by   the    corresponding 
breaking-down  process,  so  that  the  whole  routine  is  repeated  on  an 
ever-increasing  scale  of  size.     The  cavities  may  fill  and  refill  with  fluid 
exudate;  if  a  secondary  infection  of  their  contents  occur,  the  process 
becomes  more  freely  suppurative  and  in  most  cases  more  active.    Tin- 
walls  are  ragged  and  fibrous  and  may  be  lined  by  a  typical  "pyogenic 
membrane."     Most  resistaiu,  the  svpUi  and  the  blood  vessels  may  Ix 
left  bridging  the  cavity,  a!id  when  the  latter  are  eroded  or  form  small 
aneurysms  and  break,  hemorrhage  occurs.     Hemorrhage  may  occur  in 
the  most  mimite  ca\ity  and  thus  ma\   be   the  first   ^vmptom  to  hv 
observed.      When  a  cavity  opens  into  a  bronchus  and  discharges  its 
contents,  it  is  likely  that  not  all  the  latter  will  be  expelleii,  but  tlicy 


THE  LVSaS 


401 


may  hv  asi)irate<l  olsewlu-re  and  set  up  a  tuberculous  bronchopneumonia 
ill  the  tissue  nearl)y.     Should  the  infective  agent  in  this  material  be 

Fiu.  228 


liilK'rrlo  from  a  case  of  tuljerculosis,  of   mediimi  severity,  of  the  lutiR:   «,  central  caseation,  ft,  a 
Kiant  cell;  c   entlothelia!  rells;  (/,  connective-tissue  zjne  infiltrated  with  lynipliocytes. 

Fig.  220 


^"  tun  thrnuKh  early  api-  ul  tubercle,  showing:  n,  central  rasoation;  ft,  surrouodinff  cellular  infil 
■  Mnri  v^it|,  fihrosis;  c,  giant  cell;  d,  congested  capillary  outside  tubercle,  the  tubercle  itself  being 

V'.ni   nf    V('s,«*clw, 


;Ih  tiilKTcle  hacillus,  the  resulting  pneumonia  will  l)fc  truly  tubrrrulmis, 

I  lit  if  jnogenie  cocci  be  present,  they  may  set  up  pneumonia,  strictly 

nuiclitipiieiiuiouia  in  a  tuberculous  lung.     It  does  not  greatly  matter 


462 


THE  RESPIRATORY  SYSTEM 


which  is  tlie  case,  so  far  as  the  patient  is  concerned.  Such  an  infection, 
if  tuberculous,  may  give  origin  to  a  bronchitis  in  which  tubercles  form 
in  large  numbers  along  the  bronchial  tree  and  subsequently  coalesce,  so 
that  large  caseous  masses  may  be  produced,  each  surrounded  by  a  zone 
of  simple  pneumonia.  The  avascularity  of  such  a  large  caseous  mass 
is  of  importance  in  that  the  breaking-down  process  goes  on  the  more 
rapidly.  Seen  post  mortem,  the  lung  is  generally  adherent  to  the 
thoracic  wall,  weighty,  the  upper  lobe  largely  caseous  with  multiple 
cavities,  while  caseous  nodules  are  scattered  through  the  rest  of  the 
lung,  the  largest  in  the  lower  lobe  being  usually  at  its  apex.  Variously 
sized  cavities  may  exist,  or  the  upper  lobe  niaj  be  converted  into  a 
thin-walled  bag  containing  air,  pus,  caseous  matter,  detritus,  and  occa- 
sionally blood.    The  more  chronic  the  process,  the  more  smooth  and 


Tub.T(ul.Jii»  lavity  („)  at  apii  of  lung,  showing  its  relation  to  a  bronchus.      (Pathologiral 
-Mubiuni,  MiCJill  I'liivi'raity.) 

fibrous  are  the  walls.  The  bronchi  a  Hflamed,  often  ulcerated,  and 
usually  connnunicate  with  some  of  the  lavities,  which  often  communi- 
cate with  one  another.  This  slate  of  the  lung  is  called  chronic  ulcerative 
tuberculosis  or  phthisis. 

The  above-described  i)rocess  is  frequently  seen;  other  rarer  types 
of  tuberculosis  are  described  under  many  different  names  which  are 
rarely  used  in  a  uniform  fashion.  Without  going  especially  into  this 
part  of  the  subject  it  may  be  said  that  all  are  permutations  and  combi- 
nations of  three  original  kinds  of  reaction:  (1)  the  individual  tubercle, 

(2)  small  or  large  coalesced  areas  of  tuberculosis  with  caseation,  and 

(3)  tuberculous  lobular  pneumonia.  Most  cases  of  the  disease  at 
autopsy  show  all  three;  now  one  form  of  reaction  is  more  prominent 
clinically,  now  another.  There  are  two  forms  frequently  referred  to 
which  require  mention:  "galloping  c<;:i.^uniption"  und  "fibroid  phthisis." 


warn 


mmsr 


THE  LUNGS 


463 


"Calloping  consumption"  or  acute  pneumonic  phthisis  is  a  term  apt  to  be 
applied  carelessly  to  any  form  of  pulmonary  tuberculosis  that  runs  a 
very  acute  course,  but  should  not  be  used  to  describe  the  generalized 
lu'iiiatogenous  miliary  type  of  the  disease;  it  is  characterized  by  a 
\virlcs[)read  caseous  pneumonic  state  of  a  lobe  or  a  whole  lung— is,  in 


Fio.  231 


2  cm. 


I'll  lung,  siiiJtTior  loho,  and  upper  part  of  lower  lobe,  the  former  containing  a  niimber  of  communi- 
'  'iiii;  liivcrns,  brought  about  by  tuberculous  infiltration,  caseation,  and  evacuation  of  the  contents 
'111 'Muh  111,;  l)ronclii:  .1,  aneurysmal  ililiitation  of  an  artery  spanning  oi.'e  margin  of  a  large  cavity; 
".  ■  ■iimiuni,  atioii  with  another  cavity;  C.  C,  thickened  and  adherent  pleura  between  the  two  involved 
I'll  -  Tlic  pleura  over  both  lobes  ia  thickened,  and  at  the  autopsy  the  cavity  had  been  obliterated 
!'■  iinivcrsiil  adhesion;  D,  a  amall  group  of  tubercles  in  which  caseation  is  just  l>eginniDg;  E,  a  fused 
ii'  li.nf  lubcTclos,  farther  advanced  that  at  D.    (Hare.) 

f;i'  t,  a  combination  of  caseous  tuberculosis  and  '^npumouia,  the  lesion 
l"'>l^lns,r  microscopically  like  the  former  and  the  in  olvement  resembling 
tliat  i)f  the  latter  disease.  "Fibroid  phthisis"  is  merely  a  very  slowly 
I'lnirrpHsing  ulcerative  tuberculosis,  in  which  there  is  ample  time  and 
Mmiiilu.s  for  a  marked  degree  of  protective  fibrosis  to  occur.  The 
!i  'rous  solidification  of  lung  tissue,  with  its  contraction  and  consequent 


mr^fw 


at  'j«  eo^^z-TK^-V.^*- . 


4(;4 


THE  RESPIRATORY  SiSTKV 


ddorinity  of  tlic  liiiifr  and  i-\«mi  of  the  chest  are  the  itrikiiig  features 
of  this  type  of  *^\il)erciilosis. 

Hematogenic  Tuberculosis.  This  form  of  the  disease  is  characterized 
hy  the  disseiniiiatioii  of  tlie  haeilh  hy  the  hlood  either  in  the  lungs 
alone,  or  in  the  lungs  in  connnon  with  all  the  organs  of  the  hody.  A 
caseous  focus  breaking  into  a  vessel  or  intt)  a  large  trunk  of  the  lymphatic 
system  is  the  usual  cause,  and  the  widesjjread  occurrence  of  tubercles 
in  s(t  many  foci  at  once  brings  it  about  that  death  occurs  before  any 
considerable  degree  of  enlargement  and  caseation  occurs  in  any  one  of 
them. 

Fio.  232 


Fio,  233 


Caseous  hibiTi-iilosis  (»n  pussinK  on  to  cusrot 
pmuiiioiiia.     (Paili.  Mils,  MiGill  liiiv  ) 


Ht'iiiatoKonous    miliary    ttiiw^ri'Mlosis   oi 
liinc      (I'alh.  .Mu».  MrGill  I'niv  ) 


The  lung  so  affected  is  hyi)eremic,  heavy,  and  the  tubercles  are 
felt,  or  later  seen,  as  shotty,  granular  particles  in  enormous  numbers 
in  the  tissue,  throughout  both  lungs  in  the  generalized  disease,  in  one 
or  a  part  of  one  in  the  locai  forms.  The  bronchi  are  reddened.  From 
the  small  size  of  the  tubercles  (Fig.  2:53)  each  has  been  likened  to  a 
inillct  seed  {wili.i)  and  the  term  miliary  has  been  given  to  them. 
Tubercles  of  the  same  small  size  and  miliary  appearance  may  also  at 
times  be  encountered  as  the  result  of  bronchogenic,  not  hematogenic 
infection;  in  such  a  case  their  arrangement  is  not  uniformly  dift'nsc; 
they  occur  in  little  grape-like  clusters  along  the  course  of  individual 
bronchi. 

Lymphogenic  Tuberculosis.— Infection  of  the  lungs  may  occur  from 
a  tuberculous  caries  of  the  spine  or  rib,  and  occasionally  by  direct 
extension  from  a  lymi)h  node;  the  most  frecpient  example,  ho\vc\(T. 
is  the  secondary  spread  of  the  disease  in  the  lung  itself.  Under  this 
heading  it  may  be  jHiiiited  out  that  there  is  still  debate  as  to  the  j'iirt 
played  by  the  pleura  and  its  lymi)liatics  in  the  origin  of  apical  tubercu- 
losis. It  is  held  by  some  that  the  i)lcural  cavity  becomes  infected  from 
the  lower  cervical  lymph  nodes,  and  from  this,  infection  most  ea  iiy 
involves  the  apical  region  of  the  lung. 

Syphilis.-  .Syi)h'  of  the  lung  is  rare,  and  seen  oftenest  in  the  new- 
born.    No  doubt  some  cases  considered  as  syphilitic  bronchitis  and 


THE  TUNGS 


465 


pneumonia  are  merely  instances  of  a  mixed  infection  occurring  in 
s.v|)liilitic  i'ubjects.  The  disease  proper  manifests  itself  as  an  interstitial 
fibrosis  or  as  gummas.  Gummas  are  rare,  found  oftenest  near  the  hilus, 
and  if  healed  may  leave  a  fissure  forming  a  false  lobe  (pulmo  lobatus). 
(irayisii,  translucent  whei.  small,  gummas  may  in  their  later  stages 
iipjuar  very  like  tube'-cles.  The  diffuse  interstitial  form  is  due  to  a 
^'('iicral  widespreii  '  infiltration  by  inflammatory  products  that  can  be 
fiadily  understood  by  anyone  who  has  stt-n  the  enormous  numbers 
of  spirochetes  that  infest  the  lung.  The  anemic  pallor  of  the  organ 
!ias  led  to  the  condition  being  described  as  white  pneumonia. 

Actinomycosis.— Actinomycosis  o  irs  in  the  lung  both  as  a  primary 
and  a  secondary  infection,  conveyed  from  the  mouth  by  inhalation, 
or  l)y  extension  from  the  mediastinum  or  oesophagus.  Sometimes 
manifest  as  miliary  noddies,  it  ^lay,  nevertheless,  set  up  a  broncho- 
imeunionia  and  consolidation  with  ca\'tation  may  be  found.  If  very 
chronic  and  long  continued  a  fibroid  lung  may  result. 

Glanders.— Like  actinomyces,  the  B.  mallei  may  set  up  an  acute 
pneinnonic  process  or  a  chronic  state  characterized  by  multiple  miliary 
Modules,  hardly  to  be  diagnosticated  except  by  the  discovery  of  the 
l)a(illus. 

Various  Infrequent  Infections.— There  are  certain  organisms  that  have 
Ixrn  found  infecting  the  lung,  capable  of  setting  up  either  caseacing 
i;ranulomas  or  diffuse  pneumonia  or  abscesses.  Cladothriz,  streptothriz, 
some  of  the  hyphomycetes,  aspergillus,  and  even  animal  parasites,  such 
as  strongylus  and  distomum  Westermanni,  have  been  found.  Echlno- 
coccus.  carried  from  the  liver,  may  form  cysts  in  the  lung  as  elsewhere. 

Regressive  Changes.— We  have  already  spoken  of  the  atrophy  of 
the  lung  seen  i.i  emphysema  (see  Fig.  217,  page  432).  Here  we  would 
iiKreiy  recall  that  this  emphysematous  process  is  often  secondary  to 
a  !ironressi\e  atrophy  and  disappearance  of  the  elastic  tissue  of  the 
luni:.  The  «.  b'-onic  deposit  of  fibrous  tissue  around  the  arteries  and  the 
l)ronclii  seen  in  the  old,  the  so-called  periarteritis  and  peribronchitis,  is, 
a>  the  names  imply,  usually  regarded  as  an  inflammatory  condition.  It 
i-  pt  rliaps  more  properly  considered  as  a  progressive  than  n,  regressive 
cli:ini;i'. 

Progressive  Tissue  Changes.— Hyper        .y  may  be  said  not  to 

""IIP  in  the  lung,  increase  in  size  being  .  physematous,  not  hyper- 
tn  pliic.  Tumors  of  primary  nature  are  rather  rare;  of  benign  growths 
fibroma,  lipoma,  chondroma,  and  ostooma  are  found,  the  last  named  not 
t'l  lie  confounded  with  the  metaplastic  formation  of  bone  previously 
iiHut.oned;  adenoma  and  teratoma  are  of  great  rarity.  While  the  lung 
I-  I  common  site  for  secondary  malignant  tumors,  especially  those 
cirrud  in  the  blood  stream,  primary  malignant  tumors  are  not  \ory 
'  "iiinion.  Sarcoma  is  found  arising  from  the  lung  tissue,  Ijrmphosarcoma 
tr.hi  the  lymph  tissue,  especially  at  the  root  of  the  lung,  and  endo- 
ihelioma  from  the  lining  of  the  lymphatics  or  from  the  pleura.  Primary 
carcinomas  may  originate  in  the  bronchial  or  the  alveolar  epithelium 

30 


4(i() 


THE  RKSPIRATOHY  SYSTEM 


or  III  the  ponlm.iicliial  imirous  glands,  und  are  important  from  tli 
fre(,ueiuy  with  which  they  i)rojeet  into  and  J)Ioek  tlie  F)ronchi,  wit 
resultant  eoUapse  of  the  lung  tissue.  All  tumors  that  pro(lu( 
secondaries  ajipear  witn  fai  frequency  in  the  liinj;,  especially  th 
chorioepithelioma,  whose  tissue  of  predilection  it  is. 


THE  PLEURiE 

The  i)leur!e  are  sacs  composed  of  i  thin,  loose,  connective-tissii 
menil)rane  containing;  numerous  blooii  vessels  and  elastic  fibrils  hik 
covered  l)y  a  sinjile  la>  er  of  Hattened  endothelial  cells.  These  sac-wall 
henm  normall.-  m  perfect  ai)i)ositioii.  ihe  i)leural  cavities  are  non 
existent.  Any  content,  therefore,  constitutes  an  abnormalitv  Xoi 
very  i.rone  to  primary  disease,  they  often  suffer  by  the  contiKuitv  oi 
the  Junp,  and  by  the  relatively  free  lymphatic  communication  witl 
the  pericardium  and  the  jH-ritoneuni.  The  course  of  anv  disease  ,.l 
the  pleura  is  influenced  by  the  constant  movement  inseinirable  from 
res|)iration.  ' 

Circulatory  Dwturbances.-Hyperemia.-Active  hyperemia  occurs  in 
int^animatory  attections  and  with  congestion  of  the  lung  proper,  and 
occasiona  ly  from  relaxation  of  tension  when  th..racentesis  lias  been 
performed,  ^^\n\v  passive  hyperemia  is  found  in  obstnicticm  to  the 
greater  or  le    er  circulation. 

Hemorrhage.--  Petechiie,  ecchymosis,  or  even  hemorrhage  maA-  arise 
from  trauma,  in  suHocation,  in  renal  and  cardiac  disease,  in  Severe 
intections  and  intoxications  and  in  instances  of  the  hemorrhagic 
diathesis.  '^ 

The  Existence  of  Contents  in  the  PleursB.-Hematothorax.- «I„,mI 

may  be  efluscl  into  the  pleural  cavity  in  wounds  of  the  chest  such  as 
fracture  of  the  ribs,  inv.'ving  the  pleura,  or  hv  the  bursting  into  it 
ot  an  aneur>sm,  in  which  cases  the  blood  mav  be  unmixed  Often 
however,  it  is  mixed  with  transudate  or  some  product  of  inflammation,' 
as  111  the  case  ot  certain  forms  of  pleurisy-,  with  .lew  growth,  or  when 
a  tuberculous  or  gangrenous  cavity  ruptures  into  it 

Hydrothorax.-  This  consists  of  the  presence  of  a  transudate  in  the 
pleural  cavity,  occurring  oftenest  on  the  right,  frequentiv  on  both 
si(..'s.  Ihe  explanation  offered  for  its  greater  frefpiencv  on  the  right  is 
that  a  distension  of  the  right  side  of  the  heart  j.resses  upon  the  veins 
of  that  side  lenral  adhesions  may  localize  the  fluid  to  a  part  of  the 
cavity  attected.  1  he  fluid  is  usually  pale,  straw-colored,  alkaline,  of  a 
specihc  gravity  of  J(M)!)  to  1(.12,  containing  2  to  5  per  cent,  of  albumin; 
microscopically  it  contains  nothing  but  accidental  leukocvtes  and 
desquamate,!  endothelial  cells.  The  surface  of  the  pleura^  renu.ins 
smooth  but  in  long-standing  ca.ses  becomes  thickened  and  even  nearlv 
by  reason  ot  overgrowth  of  the  fibrou;;  tissue. 

A  small  amount  of  fluid  may  t-ansude  into  the  pleura  during  the 


TIIK  I'LEIR.H 


407 


.ic.ili  iip.ny,  hilt  j)leiitifiil  transudations  are  found  in  nt-phritis,  broken 
.niM|Hiisation  of  the  heart,  cirrhosis  of  the  Hver.  hvdremia.  an<l  pul- 
iMoiiMry  (edema.  A  small  collection  of  fluid  is  of  no  sijrnifieance  hut 
th.'  liiFKcrones  lead  to  displacement  of  the  heart,  media'^tinal  structures 

II Mil  lllllJIS.  ' 

Chjhnm  Hydrothimix.-lhh  consists  <,f  an  admixture  of  the  fluid 
with  tat  Klohules,  Rranular  material,  and  lymphoid  cells,  rendering 
It  opiKine  and  whitish,  and  is  caused  hy  a  rupture  or  obstruction  of 
tlic  thoracic  duct  above  the  point  where  it  enters  thi-  thorax 

Fneumothorw  -  This  is  the  term  used  to  designate  th.-  presence  of 
Mir  III  the  pleural  cavity.  By  reason  of  the  nature  of  the  exciting  causes 
tlMTc  IS  iisualy  inflammation  present  and  the  cavitv  contains  not 
.Mily  air  l.ut  also  .serun>  (hydropneumothorax),  or  pus  (pyopneumothorax). 
Al.chamcally  it  may  he  produced  hy  a  penetrating  wound  of  the 
cli.-t,  even  hy  thoracentesis;  most  commonly  it  follows  the  rupture  of  a 
tiilMTcuious  or  gangrenous  cavity  through  the  pleura  during  a  severe 
[.Mn.xysm  ot  coughing;  an  empyema  may  rupture  into  the  lung  or 
iiir  lor  «as)  ,„ay  come  from  the  ,VM.pl.agus,  stomach  or  bowel  previouslv 
r.iid.nd  adherent  to  the  pleura  or  to  the  pleura  and  diaphragm  bv  new 
irrouth.  'ertain  varieties  of  pneumothorax  mav  be  difl-erentJated • 
Ml  open  pneumothorax,  in  which  air  passes  freelv  in  and  out.  C>)  val- 
vular pneumothorax,  in  which  an  oblique,  valve-like  opening  allows  air 
tn  .liter  hut  not  to  escape,  and  (;i)  closed  pneumothorax,  in  which  the 
"Pcniiii:  has  become  occhuled.  Pneumothorax,  without  i)erforation 
iirlnisn,  "'       '  "''''"*  "^  **"  '"faction  of  the  pleura  by  a  gas-producing 

The  cticct  of  pneumothorax  depends  ujjon  the  cause  and  the 
l-rMstciice  o  the  communication  with  the  outside;  while  the  fistula 
rcnmiiis,  the  ung  will  be  collapse<l  unless  prevented  from  so  doing  bv 
'i'lli<»nns.     \M„re  a  valvular  opening  is  present  the  cavity  becomes 


>ij..n.  and  more  d:.te,.ded  until  the  heart  is  pushed  over  and  the  dia- 
I'hni^MM  .lepressed;  If  there  be  no  infection,  ami  the  woun.l  be  closed 
ilM' air  may  he  gradually  absorbed  and  the  lung  may  resume  its  natural' 

Inflammation.  Inflammation  of  the  plcu-a  (pleurisy,  pleuritis)  is 
".'ll.v  Mt  np  In  extension  of  the  disease  from  an  organ  nearbv  or 
;;•  Nu.ta>tat,c  at  cction.  part  of  a  general  disease,  as  i^  seen  in  bac 

nn  „".„;.  r"'*'^  ™f-''>''  ^"'»P»^te  or  partial,  and  is  either  exudative 

'r  Poduc  ve;  the  exudative  form  may  arise  in  a  pleura  alreadv  the 

.1    t  a  prodiic  ivc  inflammation  or  the  exudative  form  mav  develop 

1  e  productive.    These  two  forms  ..re  really  expressions  of  a  more 

•'  '■'  ■'  1'^^ '"  ■     intectum. 

'-h'^^mS^'^  ''''"'  ^'^^'"'^''  "^"••'  ^^'^  '^  ^hut  in,  unable  to 

Pla  ac  neuriLi       '     "'""•'    l"'""^  aPPearances;  it  may  be  fibrinous 

•        rrln'i  '"■""''   ^*""'^^""""^-   fibrinopurulcnt,  purulent,   or 


lirli 


4r»s 


THE  RESPIRATORY  SYSTE.\f 


Fibrinoua  Pleuriay.  -In  this,  the  scM-allid  "dry"  pleurisy,  the  j)Ipnra 
is  opatjue,  and  covered  by  a  delicate  hiyer  of  fibrin  which  s<-arct-Iy 
resists  removal.  This  consists  of  interlaced  threads  of  fibrin,  with 
leukocytes,  and  bacteria;  the  vessels  of  the  subjacent  lung  and  of  the 
pleura  are  congested,  and  fibrin  may  b«-  seen  in  the  tissues,  which  are 
a'dematous  and  show  a  certain  amount  of  cellular  infiltration. 


Fia.  234 


b  _ 


Section  from  a  case  of  serofibrinous  pleurisy  (high  power) :  a,  congested  and  infiltrated  aubpl  ural 
lung  tissi  e;  h,  fibrous  layer  of  pleura  also  infiltrated  and  devoid  of  endothelium;  c,  c,  denser  bands 
of  fibrin;  d,  d,  loose  nieshwork  of  fibrin,  infiltrated  with  scrum  and  leukocytes. 

Serofibrinous  Pleurisy.— Few  pleurisies  remain  dry,  and  there  is  usually 
an  outpourinK  <>f  fluid  into  the  cavity  (pleurisy  with  effusion);  this 
fluid  is  yellowish,  and  if  mixed  with  many  cells  and  shreds  of  fibrin, 
turbid.  In  the  dependent  parts  of  the  cavity  and  sticking  to  the  walls 
of  the  pleural  cavity  are  shaggy  masses  of  fibrin,  bright  yellow,  some- 
times gelatinous,  and  at  times  w  thick  as  to  form  a  regular  blanket 
which  it  requires  some  force  to  tear.  The  amount  of  fluid  may  vary 
from  a  few  cubic  centimeters  to  several  liters,  it  coagulates  readily 
with  heat  and  sometimes  spontaneously  on  removal;  its  specific  gravity 
is  high  (1025  or  more)  and  it  contains  much  albumin  as  veil  as  sdine 
uric  acid,  cholesterin,  and  sugar.  Microscopically,  it  hows  fibrin, 
leukocytes,  red  corpuscles,  endothelial  cells,  and  bacteria.  The  condi- 
tion of  the  lung  varies  with  the  amount  of  fluid;  it  may  be  almost 
completely  collapsed,  the  heart  disj)laced,  and  the  diaphragm  (and  with 
it  the  liver)  depressed.  The  collapsed  part  is  tough,  gray,  or  gra.\  i-li 
brown,  or  even  bluish  in  color,  and  is  non-crepitant.    If  not  heltl  by 


THE  PLF.VR.E 


469 


iHlhcsions,  the  fliii«l  moves  with  the  patient's  change  of  posture.  When 
h.iilinj;  occurs  the  fluid  is  Kradually  ahsorhed  by  the  lymphatics,  the 
lil.nn  l)rcaks  up,  and  no  sign  of  trouble  may  remain  except  a  slight 
ilii(  kcning  of  the  pleura.  Oftener,  however,  some  organization  of  the 
lil.rous  layer  occurs,  so  that  the  visceral  and  parietal  layers  of  the 
plnira  r.-main  adherent.  With  the  lapse  of  time,  the  adhesions,  being 
( onstaiitly  pulled  upon,  become  thin  and  veil-like;  such  adhesions  are 
otteii  seen  l)etween  lobes  and  on  the  posterior  surface  of  the  upper  lobe, 
and  in  some  cases  the  pleural  cavity  may  be  entirelv  obliterated. 

Purulent  Pleurisy  (Empyem*).— This  may  arise  from  a  serofibrinous 
pleurisy,  or  as  a  complication,  sometimes  a  sequel,  of  pneumonia,  or  from 
I  hi-  rupture  of  a  tuberculous  or  gangrenous  area  in  the  lung,  or  more 
ranly,  a  subdiaphragmatic  abscess  or  a  diseased  viscus  may  perforate 
uito  the  pleura.     In  children  it  occasionally  seems  to  be  primary.     The 
•  xudatc  consists  of  thin  or  thick  pus,  and  the  action  of  the  pus  cells 
t.n.ls  to  digest  the  fibrin.    If  putrefactive  organisms  be  present,  the 
pus  JMconies  very  fetid.    If  the  condition  be  not  relieved  surgically, 
the  consequences  may  be  very  serious;  the  patient  may  die  of  exhaustion,' 
ot  toxcnua,  or  the  pus  may  rupture  into  the  lung  with  formation  of 
pyopneumothorax,  or  through  the  chest  wall  (empyema  necessitatis),  or 
into  neij;Iil-,oring  organs.    If  unrelieved,  it  occasionally  happens  that  the 
fluid  IS  absorbed,  the  pus  becoming  inspissated,  and  later,  infiltrated 
with  calcareous  salts,  so  as  to  ft)rm  a  .solid  plaque.    Should  the  patient 
survive  there  is  usually  great  thickening  of  the  pleura  and  even  deform- 
it\ ot  the  chest.    Practically  it  must  be  remembered,  in  viVw  of  the 
serious  nature  of  the  disease  and  the  readiness  with  which  it  may  escpoe 
recognition,  that  the  physician  will  oftener  regret  his  delay  than  his 
I>re(ipitaiicy  m  the  use  of  the  exploratory  puncture  needle  in  a  doubtful 
case. 

Hemorrhagic  Pleurisy.— Bloody  exudate  is  found  in  tuberculous 
pleuri>y  or  where  new  growth  is  present  in  the  cavity,  although  not 
<■!  iHcessity;  further,  it  may  occur  in  the  very  debilitated,  or  those 
sullerniK  trom  scurvy,  icterus,  or  the  hemorrhagic  diathesis. 

Productive  Pleurisy.— This  may  be  a  late  development  of  a  simple 
eMi,  ative  pleurisy,  or  may  arise  insidiously  as  a  primary  affection. 
Miulit  (legrees  of  thickening  of  the  pleura  are  pathologically  unimporiant 
;nid  clinically  equally  so.  In  the  more  marked  cases  the  pleura  is 
"in.li  thickened,  even  to  a  centimeter  or  more,  becoming  a  white 
'I'enil.raiie,  sometimes  of  a  pearly  or  cartilaginous  appearance,  and 
'H  extreme  cases,  resembling  the  icing  that  is  put  upon  a  cake  (hyalo- 
serositis). On  microscopic  examination,  this  proves  to  be  layered,  and 
'"lierwisc  almost  structureless,  save  that  in  its  deepest  parts  there 
!^  ^li^'lit  vascularization;  the  lung  is  apt  to  participate  in  the  state  of 
""I'lratioii,  and  often  a  neighboring  serous  surface  is  likewise  involved, 
'  -I-eiially  the  peritoneum  over  the  spleen  and  liver.  With  the  lapse 
>'=  -'lie,  calcareous  masses  or  plates  of  cartilage  and  bone  are  formed. 


470 


TUK  HESrinATOHy  SYSTK.Xf 


n  • 


TJib«rcul08ii  o{  the  Pleura.  \„t  infm,.untly  a  patin.t  pnvi..u.slv 
lu-altl.y  .|,.y,.|..ps  pleurisy  with  rtruMon:  such  a  plnirisv.  oominic  "oiit 
of  u  .loar  sky  is  likely  f.  hv  ti.I..T.ul...is,  aii.l  ov.-n  if  "no  l.>s.<m  of  the 
liiiiK  or  elsewhere  he  fciiii.l.  it  is  i.e.-.lfMl  to  consider  that  the  patient  is 
tuherculous  until  it  is  pr.-ve.l  that  lu-  is  not.  The  tulHTeuh.us  infec- 
tion m  such  a  case  has  l,.-en  picked  up  from  the  lymph  imhIcs  or  from 
a  focus  in  the  Iuuk  too  small  to  he  .lis,„vered  hy  physical  examination 

1  he  pleura  may  he  atVected  as  part  of  a  general  miliary  infection 
or  from  a  tuhercuh.us  hronchopneumonia;  in  the  former  case  the 
tubercles  alone  may  he  seen,  and  inflammatory  reaction  in  the  ordinary 
sense  ot  the  term  is  yery  sli^'ht.  while  in  the  latter,  aft.-r  the  fibrin  ha's 
been  remove.1,  the  tubercles  show  on  the  surface  of  tl»-  pleura,  indicat- 
ing the  nature  of  the  infection.  It  must  be  remembered  that  there 
are  cases  showing  no  obyious  tubercles,  appearing  to  be  cases  of  simple 
serous  pleurisy,  m  which  inoculation  of  the  flui.l  into  animals  sets  up 
tuberculosis  In  a.lyanced  cases,  considerable  caseation  may  be  found 
layer  after  layer  of  tubercles  uiulergoing  in  succession  the  necrotic 
change. 

Harel.N-,  syphilis,  leprosy,  and  certain  parasites,  such  as  echinococciis, 
psorosperms,  and  entam(Kba  coli  haye  been  known  to  affect  the  pleura 

Progressive  Tissue  Changes.  -  Tumors.-()f  benign  growths,  flbroma,' 
Upoma,  chondroma,  osteoma,  an.l  angioma  afiVct  the  pleura;  of  malignant 
growths,  the  most  important  is  endotheUoma,  \vhicli  is  found  in  the 
pleura  more  often  than  anywhere  else,  saye  the  dura.  It  may  be  soft 
and  c.rcuniscribe.1  but  more  often  is  firm,  flattencl,  and  cancer-like. 
Sarcoma  of  the  pleura  is  occasionally  found  in  the  young;  various 
combination  forms  of  sarcoma,  such  as  angi..-,  fibre..;  and  chondro- 
sarcoma are  met. 


Hi 


THE  MEDIASTINUM 

The  mediastinum  is  that  i)art  of  the  thora.x  which  lies  between  the 
two  pleura-,  the  sternum  and  the  yertebral  column.  Since  it  is  a  space 
containing  many  organs  and  diHerent  sorts  of  tissue,  and  not  an  organ 
or  system  of  organs,  its  diseases  cannot  be  taken  up  in  any  rational 
or  sequent  way;  some  generalities,  howeyer,  are  necessary.  leaving 
aside  the  yessels,  neryes,  muscles,  the  trachea,  tt-sophagus.  thymus, 
and  the  thoracic  duct,  we  haye  still  left  for  cc.nsideration  the"  Icse 
connectiye  tissue  that  lies  among  these,  and  the  yery  important  groups 
of  lymi)h  nodes. 

Inflammation.- Mediastinitis.-Mediastinitis  is  inflammation  of  this 
connet^ne  tissue;  it  will  be  seen  that  such  can  arise  in  many  different 
ways,  by  trauma  or  l)y  extension  from  any  of  the  numerous'structures 
referred  to  as  occupying  or  bounding  the  space,  or  finally,  bv  the  infectix  e 
agent  be-ng  carried  thither  in  the  blood.  An  inflammation  may  res<.lve 
or.  on  the  contrary,  may  progress  to  the  formation  of  an  absce.ss.  whi.h 
may  rupture  to  the  outside  or  into  one  of  the  many  organs  of  which 


THE  MEDJASTISrSt 


471 


It  has  clKHfc.  ShoiiM  a  coiisi.leral.lo  itiflaminiition,  which  has  not 
l.r.ii  suppurative,  bocoinc  l.i-alo.l,  nu'diastinal  .ulhesions  are  apt  to 
r.Miain:  thfsf  may  link  tlu-  p«Ti«-ar<liinn  to  tlic  cliest  wall,  or  the 
IHrirjirdiiini  to  i\\v  pU-iira-,  ami  i-  !,<•  .so<l«-nse  and  nmnerous  as  to 
oi.htrratt'  tlif  space.  Apart  fn.ni  such  acute  <lisease,  ti.e  slow  pro- 
srr.  -ivc  uiHamniation  spoken  of  as  prtKlncinK  the  thickening  resemhlinR 
a  <akc  icniK  tends  to  affect  the  nu-iliastinal  tissues  aloiij?  with  the  pleura 
am!  the  pericardium. 

In  the  freqnent  references  made  to  thoracic  lymph  ncwles  as  the 
l>la(rs  in  which  tubercle  bacilli  and  other  infective  ajfents  lie  latent  or 
Irnni  which  tlii-y  set  out  to  infect  the  Ixnly  at  larjte,  the  lar^e  groups 
ot  nodes  \n  tiicmcliastinum  are  those  referrc<l  to;  not  oidv  those  which 
arr  strnnn  alonj;  the  course  of  the  vessels,  the  (esophagus,  and  the 
trach.a.  but  the  iarye  jfroups  at  the  bifurcati(m  of  the  trachea,  and 
around  each  bronchus.    The  si/e  of  these  groups  and  the  importance 

Fio.  235 


r„l..  r.  ulo»H  „f  lj,„„h  nodes  bclov   •..ifureation  of  trachea  in  a  cl.ild;    a.  enlarged  caseous  node. 
(M  Gin  Pathological  Museum.) 

"t  thr  tracts  they  guard  make  them  of  great  use  in  handling  large 
•I'noiints  ot  mfective  material,  from  which  the^  are  necessarilv  liable 
f"  injury.  It  is  m  them  that  signs  of  latent  and  healed  tibc'rculosis 
ar.cttencst  tcjund.  Simple  inflammation  of  these  groups  mav  lead  to 
'I"  ir  ;;r,.at  enlargement,  and  to  consequent  pressure  upon  the  viscera 
I"  'I"'  space,  or  to  their  adhesion  to  the  wallt  of  viscera,  such  as  the 
"  "i-haiius,  with  subsequent  deformity  of  the  same  bv  traction. 

Progressive  Tissue  Changes.-  Tumors.-Considering  the  tumors  of 
"  ■  in.dmstimim,  the  multiplicity  of  tissues  makes  it  possible  to  have 
"..-nx  .htterent  forms  of  nev  growth;  the  only  forms  that  require  special 
■'■■  ntion  are  the  dermoid  cysts,  which  arise  from  Ue  thvmus  gland  or 
f  n,  .i.il.last  shut  in  at  the  closure  of  the  tlunacic  wa!!.  These  are  soft, 
I'  "  ''i:int.  and  are  apt  to  transmit  pulsation  from  the  great  vessels,  so 
■  iiity  may  be  mistaken  for  aneurysm.  There  is  danger  that  they 
''  '     rupture  mto  some  important  structure.     Teratomas  proper— 


472 


THE  RKSI'IRATORV  SYSTE.Xt 


foetal  inclusions-  arc  rarely  nicountercd.    Sarcomk  is  the  most  comm 
mnhKnant  tumor  of  tlu-  nuMlinstinnm.  urisinR  eitlu-r  from  the  connective 
tissue  or  from  the  Ivrnph  structures,  fn.m  which  lympliMWComM  of 
enormous  size  Rrow.      Many  of  these  mediastinal  tumors,  however, 
oriKinate  fn.in  tl>e  lymphoirl  tissue  of  the  thymi.  .,  and  of  these  s<.me 
at  least,  exhibit   the  characters  of  an  inflamm  -,ry  Kranuloraatous 
Krowth.     .Secondary  maliKiuint  growths  ol)tainin«  pla.c  in  the  Ivnioli 
no<les  or  elsewhere  are  of  fair  fre(,ucncy,  and  are  dinicallv  important,  as 
are  the  primary  growths,  by  reason  of  the  iiJi,)ortance  of  the  structures 
ti|M.n  which  they  may  exert  pressure.      The  vagus,  the  sympathetic 
n.'rves,  the  a'soi)hagus.  trachea,  and  the  various  vessels  are  so  clos,. 
together  that  a  relatively  small  tumor   may   be  atten.lcd  bv  great 
disturbance  of  function. 


THE  THTMUS 

Tlic  th\  mus  is  developed  primarily  from  the  hvpoblast  of  the  third 
branchial  groove  just  as  the  tonsils  are  .lerived  from  the  second,  and. 
like  the  tonsils  while  originally  of  epithelial  type,  their  epithelium  l,e- 
comes  surrounded  and  largely  replaced  by  lymphoid  tissue,  the  rem- 
nants forming  concentric  masses  of  cells  known  as  Ilassall's  corpuscles 
lo   all   intents  and   purposes  it  is  a  lymphoid   organ   forming   two 
elongated  and  fused  lobes  in  the  anterior  mediastinum  and  extending 
over  the  upper  portion  of  the  pericardium.    Iteaching  its  maximum 
development  at   about   the  end  <      the  second   vear  of  life  it  then 
undergoes  a  premature  senile  atrophy  of  a  somewhat  remarkable  tv,,e. 
1  Me  lymph  cdls  pr-  -ressively  diminish  and  their  place  is  taken  at  first 
by  cells  which  contain  small  fatty  globules  and  later  f>y  what  »i)pear 
to  be  true  fat  cells.    Occasionally  it  persists  until  the  fifteenth  vear 
or  later  and  is  of  considerable  size,  with  abundant  lvmt)hf>cvtic'ele- 
nients.    Diseased  conditions  of  the  thymus  .re  rare;  them.ist  important 
is  the  thymus  hyperplasia  generally  accon  ji-tiying  the  status  lymph- 
aticus  (lymphatisiD);  this  hyperplasia  otcu-s  in  young  children,  but  ha. 
been  noted  in  you.ig  adults,  weights  of  .0.,  to  ir  grams  being  recordci, 
t..e  maximum  of  the  normal  gland  being  '.il  grams.    In  leukemia  there 
may  be  marked  enlargement  as  also  ;.i  <-ome  cases  of  exophthalmic 
Koitre     I{are  cases  of  abscesses,  tuberculosis,  and  of  syphilitic  necrosis 
nave  been  described. 

Tumors  are  rare,  with  the  exception  of  lymphosarcoma.  As  ab(>\  e 
noted.  It  appears  probable  that  a  large  proportion  of  the  diffuse,  locallv 
infiltrating  growths  of  the  mediastinum  originate  from  the  thymus  glancl. 


<'n.\i*Ti:i{  VIII 

THE  NERVOUS  .SYSTEM 


GENERAL  CONSIDERATIONS' 

UiiKN  \ye  recall  the  fxtruunlinary  ecmpUvxitv  of  the  finer  <•    —rv 
..t  the   .rain  aii.l  c.rd,  the  relatively  small  arek  of  the  .surffl.>'  ,e 

( rr.  hriil  heinisi>lieres  ui  which  we  can  recognize  the  existet- -  tres" 

.•H„tn.ll.nK  one  or  <.ther  function  of  the  b.Kly,  the  vast  ma-  .Tehrum 
nn.l  cerebellum,  regarding  the  function  of  which  we  have  n  ure  inili- 
«.iti'.„s,  the  remarkable  system  o'  multiple  associati.,ns  between  the 
nrurones.  the  great  bulk  of  data  an.l  of  hypotheses  that  has  accumu- 
li.t.Ml,  «e  conft.,s  that  it  is  ^^ith  trepidation  we  enter  up(,n  the  task  of 
.•..ini>r..ss.ng  into  a  few  pages  even  the  minimum  of  knowle.lge  require.! 
h  tl.e  beginner  ,n  niwhcine.  As  to  the  nature  of  thought  and  the 
.•.>^o,mt.on  of  uleas,  the  highest  of  all  the  cerebral  activities,  we  know 
.ni.ti.ally  nothing;  the  same  is  true  reganling  the  essential  nature  of 
"Mnu.ry ;  ,t  is  :.nly  when  we  come  to  the  relatiorihip  between  the  higher 
•rntns  an.l  certain  bodily  functions  that  we  find  ourselves  on  somewhat 
>nn  r  Kn.nnd  and  thr  because  we  can  follow  and  recognize  the  tracks 
■1  ^Miaton.u-al  change      But  even  here,  although  for  lo,^  years  investi- 

M  ;r  '  r"  '*^*^y!"8  *»»«  "*^'-^»»"*  phenomena  of  such  all-imi«,rtant 
I...  tm  as  the  periodic  activities  of  the  circulatory  an<l  respiratory 
^  M.m  there  continues  to  be  uncertainty  as  to  the  exa.-t  nature  of 
i'.nntoinatK. mechanisms  that  govern  these,  and  as  to  the  exact  site 
"'  iiic  cuntrolinig  neurones. 

uni?'\|"!lir''""''  "-T"'  •'  '""•'"  "P  ''f  * «^^^*  aggregation  of  similar 

all     Ti      '  """'*  "'"'""f  ""'^'^t^  «^  a  °«'^-"U  body,  dendrites 

■  Hi  axone.     1  he  gray  matter  of  the  brain  and  the  ganglia  possess  a 

-!"|.;..U.rance  of  nervcK^ell  bodies  while  the  white'ma'tter'and  the 

>ura    nerves  are  largely  made  up  of  axones.     The  neurones  are 

together  (or  held  apart)  by  gUa  and  fibrous  tissue     „    i,*ter,  in 

M    I   o-antity,  serving  to  support  the  blood  vessels  (.  v.m.ou,    ..'.,• 

;    i"itt  ..mph  vessels  have  not  yet  been  proved  for  t  v 

^'"    Tan,,  although  these  exist  around  the  blood  chann- 

r-'H^  IS  anato.nicall:    ^dependent  of  all  other  neurones. 

'■''■  n.rye-cell  body  assumes  varying  shapes,  has  a    ' 

I    A  '^^t'^.f  ""^'eolus,  and  in  its  protoplas. 


LiDSttli.-.,  i/i 

Kuch  i;e;i- 


v.\lX     ,   Z  f"^«^"«^  (chromophilic,  tigroid,  or  Nissi  •  ^.L.^), 

""'I'  are  presumed  to  be  of  nuclear  origin,  because  their  substanc^ 


' :. '  rentr  . ! 

;!ll!.>Pt'i!i;  <■ 


474 


THE  XEinors  sysTE.\f 


has  stain  iiffiiiitii's  Mmmvliat  like  those  i.f  the  mieleiis.  The  dendrite^ 
are  tree-like  proloiijrations  of  the  protoplasmic  siihstaiice  of  the  iierve- 
eell  body,  taperiiij;,  heeoiniiif;  smaller  as  thev  reeede  from  the  eell 
very  numerous  and  hrauehed,  serving  to  hrinj;  the  i)rot()plasm  of  one 
nerve-cell  body  into  "almost-contact"  with  other  cells.  The  term 
"almost-contact"  is  used,  because  it  is  generally  believed  that  actual 
contact  does  not  occur,  but  that  parts  of  two  nerve-cell  bodies  thus  lie 
m  juxtaposition  as  do  the  secondary  and  the  primarv  coils  of  an  induc- 
tion battery.  The  axone  or  axis-cylin,ler  is  a  process  of  the  cell,  usuallv 
Slug  e,  containing  no  cliromophilic  b.ulies  (nor  are  there  aiiv  to  be  seeii 
111  the  part  of  the  nerve-cell  body  from  which  it  takes  its  immediate 
oriKin)  and  is  of  uniform  size  throughout;  toward  its  emi  it  mav  split 
It  up  into  a  terminal  tree,  of  which  each  twig  may  end  in  an  end-foot 
or  end-plate  which  is  in  intimate  relation  (actual  contact)  with  the  eell 
ir. ;/.,  muscle)  t..  which  it  runs.  The  axone,  as  it  leaves  the  nerve-cell 
bo(  y,  becomes  iinested  by  a  myelin  sheath,  and  axones  so  sheathed 
make  up  the  greater  part  of  the  bulk  of  the  white  matter  of  the  brain 
and  c-ord.  A  number  of  sheathed  axones,  surrounded  bv  the  sheath 
ot  Schwann,  constitute  a  i)eripheral  nerve;  the  sympathetic  nerves 
possess  a  sheath  ot  Schwann,  but  are  not  myelinated. 

On  the  Correlation  of  Neurones.     It  is  duly  the  verv  simplest  reflex 
act   apparently,  that  depen<ls  upon  what  we  mav  term  a  simple  are, 
and  that  simple  arc  calls  into  play  two  neurones.    This  mav  be  laid 
down,  that  a  given  axone  ccmveys  stimuli  in  only  one  direction.     Thus, 
a  sensory  or  afferent  stimulus  has  to  be  conveved  to  the  spinal  cord 
through  the  agency  of  at  least  one  neurone,  and  the  muscular  response 
to  such  stimulus  has  to  be  conveyed  from  the  central  nervous  svsteiu 
by  at    east  one  other  ne-;n.ne.     As  already  stated,  each  neurone  is 
isolated  to  the  extent  that,  although  it  may  come  into  contact  with 
another  neurone  by  means  of  its  arborization,  there  is  not  an  inter- 
cellular union,     ("ommunicatioii  between  neurone  and  neurone  is  in 
the  torm  of  arborizations  surrounding  the  nervc-c«-ll  bodv  of  the  second 
neurone,  and    impulses  passing  down    certain  of   these  arborizations 
liave    to  jump  across  the  material,  or  synapse,   intervening   between 
them  and  the  second  neurone.     For  more  complicated  reflexes,  aiul  for 
voluntary  acts,  a  stiinuhis  may  have  to  pass  through  several  cell  relays 
before  the  act  in  response  to  the  primary  stimulus  can  be  institute'.!. 
In  the  complex,  as  in  the  simple  arc,  a  break  in  anv  one  relav  prevents 
the  response,  or  if  it  does  not  |)revent  it,  causes  definite  delav  in  its 
imxiuction,  because  the  stimulus  has  to  pass  along  some  more*  round- 
about path,  which  may  not  always  be  provided.     If  the  break  be  on 
the  afferent  side,  we  have  loss  of  sensation,  if  on  the  efferent  side,  lo-s 
of  functional  response. 

Groups  of  Neurones.     We  are  accustomed  to  recognize  three  great 
groups  (     neurones— the  afferent,  the  eH'erent,  and  the  sympathetic. 

The  Afferent  System.     The  afferent  nerv«-<  of  the  bwiy  in  general  nn' 
rejiresented  by  neurones  whose  nerve-cell  bodies  are  situated  in  the 


a E SERA  L  <  OXSIDERA  TIOXS 


475 


I.o>t.n,r  roo  gansMa  ot  the  spuml  cord.  an.  1  in  certain  corresponding 
..-<•  ne.l  ce„  res  ,n  the  bnlb  ami  pons,  and  even  farther  forwan  i,! 
t  e  lm.e  ..i  the  bran,.  Cerebral  sensory  nerves,  olfactorv.  optic,  etc 
.re  s mular  to  the  so.nafc  sensory  nerves  in  this,  that  a!  a  ike  must 
tn.nsler  their  st.nu.h  to  other  neurones  which  con.h.ct  them,  bv  n"re 
o.ssdev,.,„s  paths,  to  the  cells  of  the  cerebral  cortex,  an,    to  Sr 

1.   e.l  cells  of  the  h.gher  order.     The  apprec-iation  of  sensation  1  es 
these  ceils  ot  the  h.gher  onler,  whereas  the  reHex  act  proc    ce.l  Tn 

e  sunple  arc  may  be  accomplished  without  reference  to  the  bain 

The  Efferent  System.  -  The  erterent  nerves  of  the  bodv  are  represented 
;.v  ^.  l-vcr  Kroup  .>    neurones  whose  nerve-cell  bo.li.'    are  situa  e d1 

"t  tlu  l.rani.     Ihese,  however,  are  under  control  of  a  higher  jrroun  of 
n.nrnnes,  or  ,„„re  strictly  of  two  groups  of  neurones,  the  ^ne    vim  e 

"  I  .tn.     We  stil  are  by  no  means  informe.1  as  to  the  full  functions 

't  t  cse  two  onlers  of  neurones.    The  cerebellum  is  presumed  to  be 

'    -  antly  responsible  for  the  preservation,   by  meal.s  of  rh  thmic 

^    mm!,,  ot  the  mteract.on  of  the  muscles,  that  is.  it  e.xerts  a  sUtic 

•"•<■-'<•«'.  <-<;"t.nues,  so  to  speak,  the  .tatu.  ,,u„  of  the  bo,lv  m  sculature 

I.;|rt„res  trom  tins  state,  such  as  voluntarv  movements;  are  ,  .!^ftute<l 

I-  <ylis  ot  the  cerebral  cortex.     This  may  be  made  clearer  b^•  sav  ng 

pHMn,,!    )>  th.-  (unconscious)  tone  of  muscles,  to  illustrate  which  it 

:Zn'ci::^v^t^  """^^^^ ''  '•"^^'•"  '-*-  -tw  ;^:,; 

N  "^I'es  thiss  .f,  ■  fT  '•""^^"[•t"'.».  .Pr-FH-rly  coordinate,  of  manv 
i       .'■    e  el.         "^,/''%"'"-^^-'^'-''  '^  "'.  r-P'>"«e  to  constant  stimuli 

.        y.    ,(rel,iilar  cells;  if,  now,  one  wishes  to  move  v..luntarilv   the 

"■  :  ot  tl...  .-erebral  cortex  take  command,  and  bv  sti.nuli  reinfo  ce  the 

'■;■;-     -m..  lessen  the  acticm  of  .,thers.  intr.,.luce,  IJt^  b" 

^^    T^li\^,Ti'7  7*'''^"":^^"'  "»-'-.  a-l  -  alter  the  status  <iuo 
■I  III  w  >r.itiis  ot  voluntarv  activity 

The  Sympathetic  or  Autonomic  System.-This  system  is  a  verv  craDli- 

•     .that    he  abuulant  investigations  of  the  last  few  years  by  Langle  - 
t  u  .  ha  e  intr,,duce.l  so  many  new  p.,ints  of  view  that  it  is  ex- 
'i.Mt  luatew  words  t..  describe  either  its  anatom     orits 
'■     Hreflv,  n,  .„,n,ection  with  the  brain,  the  main  spinal  cord 

I-  t  K,r  lUTNc-cel    b..dies  withm  the  central  nervous  svstem  leave 
'-   r  otTS';':;'-''  r-'''^  '^^^''^^  ^-  ^'^  ^rain)  correspcln.  1. 
'-'^.' .  11  bo  f"  "'  "  T''  "^  ^"^^  arborizations  around  the 

I    bo.l  e..  .,t  certain  ganglia,  which,  .save  for  these  fibres   are 

'  -  .  Z'c  ;:tr;;;"V"'iK'"  ^'f^T  ''''"'^'  ^^^  exampicXS 

•   ...,,.      •  .r  ^1  ^'"^  ^^'^^  ''■'"'^''  P''«^  to  the  ciliarv  ganglia;  the 
'""'  '""1  "H.th  hbres  passing  to  the  submaxillary  and  sublingu^ 


470 


"^llE  XERVOrs  SYSTEM 


II 


gai.gha  and  to  the  sphenopalatine  and  otic  Kanglia;  the  autonomic  or 
sympathetic  fibres  of  tlie  tenth  and  eleventh  nerves  run  in  the  vagus 
and  It  seems  probable  that  these  fibres  end  in  small  ganglia  situated  in' 
or  near  each  of  the  organs  supplied  by  the  vagus.  As  regards  the  spinal 
cord,  the  sympathetic  fibres  pass  out  by  the  anterior  motor  roots  to  the 
series  ot  vertebral  ganglia,  including  the  superior  cervical  ganglia;  in  the 
sacral  region  of  the  cord,  slight  differences  of  arrangement  of  the  svm- 
pathetic  system  to  the  anogenital  region  are  observed. 

These  fibres  running  to  various  ganglia  are  the  pre-gangUonic  fibres 
which  arborize  around  the  cells  in  the  ganglia;  these  cells  in  turn  give 
oNgin  to  axones  (the  post-gangUonic  fibres)  which  course  directly  to  the 
viscera,  or  in  the  case  of  cutaneous  fibres,  return  to  join  the  spinal 
nerves  and  so  course  to  the  various  segments  along  with  the  cutaneous 
sensory  nerves.  In  whatever  ganglion  this  relav  is  situ.-it .  d,  it  appears 
that  there  is  no  further  relay,  but  that  the  axone  of  the  second  cell 
passes  direct  to  the  viscus  which  receives  the  svmpathetic  innervation 
l-or  example,  m  the  dorsal  region  we  liave  both  vertebral  ganglia  and 
the  conjoint  ganglia  of  the  solar  plexus;  sympathetic  fibres  from  the 
cord  pass  through  both  of  these  to  their  ultimate  distribution;  their 
relay  cells  may  be  m  one  or  the  other  but  not  in  both.  As  regards  the 
afferent  hbres  of  the  sympathetic  system,  these  when  present  run  in  the 
white  rami;  it  seems  that  the  head  and  the  skin  have  few  or  no  afferent 
sympathetic  fibres,  these  coming  essentially  from  the  thoracic  and  ab- 
dominal viscera.  So,  further,  it  appears  that  the  sensory  connection  of 
the  various  viscera  with  the  spinal  nerves  differs  but  little  in  arrange- 
ment from  their  motor  connection. 

Pathological  Changes  in  the  Nerve-ceU  Body.— What  knowledge  we 
possess  concerning  the  changes  that  occur  in  tlu-  finer  structure  of  the 
nerve-cell  body  is  largely  due  to  the  employment  of  Nissl's  methiKl 
which  uses  a  staining  material  compounded  of  methvlene  blue,  thionin, 
toluidm  blue,  and  neutral  red.     Small  masses  and  granules  in  the  pro- 
toplasm thus  become  visible,  arranged  in  different  wavs  according  to 
the  type  of  cell.     It  may  be  mentioned  that  experience  and  extreme 
cautu)!!  in  the  observation  and  interi)retation  of  results  obtained  bv 
this  method  are  necessary.     In  a  general  way  we  know  from  the  appear- 
ance and  arrangement  of  the  stainable  sul)stan(e  what  is  the  ph^si..- 
logica   state  of  the  cell;  the  stainable  material  (tigroid)  is  normaliv  in 
granules,  spindles,  lozenges,  rodlets,  threads,  or  shapeless  masses  oceupv- 
ing  the  interstices  between  the  fibrils;  it  is  not  demonstrable  in  the 
ernhryo,  it  increases  m  amount  within  limits  in  a  state  oi  rest,  and 
diminishes  by  activity  and   fatigue,   in   intoxications,   in   circnlatorv 
and  nutritive  disturbances,  <liminishes  in  advanced  age  and  under-o.s 
a  degeneration  into  a  finely  granular  material.     Electric  stimuli,  imi 
the  activity  consequent  upon  them,  lead  to  swelling  of  the  cell  ixuiv 
and  nucleus  and  to  diminution  of  the  stainable  substance;  if  carried  to 
the  extent  of  producing  fatigue,  cell  bodv  and  nucleus  diminish  in  size 
and  stainable  material  in  quantity,  and  vacuoles  appear.    By  section, 


'^^^^^i^' 


PATHOLOGY  OF  THE  XErF{OXE 


477 


.  mnpression,  electric  or  chemical  stimulation  of  peripheral  nerves  the 
.•lmM,..s  brought  about  m  the  cell  are  divisible  into  two  stages,  those  of 
ryM.t  M.n  ami  repair      1  he  stage  of  reaction  is  characterized  bv  a  diminu- 

lun  ..he  stainable  material  (chromolysis.  tigrolysis);  this  appears 
t..  I.e  .l.Hused  more  generally  than  usual  through  the  cell,  whose  proto- 
l.lMsni,  as  a  who  e,  becomes  more  readily  stainable.  This  dissolvinir 
action  seems  to  begin  at  the  centre,  the  cell  swells,  and  the  nucleus 
comes  to  lie  nearer  the  periphery.  These  changes  are  produced  but 
•^  mvly,  the  reactionary  state  being  visible  a  couple  of  davs  after  section 
ot  the  nerve  rema.mng  evident  for  two  or  three  weeks  and  passing 
gradually  into  that  of  repair,  m  which  the  nucleus  becomes  oncle  morf 
central  an.!  the  swelling  disappears. 

Pathological  Changes  in  the  Dendrites.-We  know  but  little  of  the 
finer  changes  that  occur  m  the  dendrites,  although  they  hax- »  been 
stu.hcd  in  dements  and  after  the  action  of  certain  poisons.  In  diseases 
oausc.l  so  diversely  as  these  we  are  able  to  see  lesions  that  are  relativefv 
.innlar;  which  means  that  the  metho,ls  at  our  .lisposal  are  able  to  detect 
only  the  most  gross  kinds  of  lesion,  while  the  finer  diflerences  enti  e  v 
cMap,.  our  notice.  Wo  can  make  out  atrophv  of  the  fibrils  swe  li,'^ 
'un  twisting  of  the  same,  and  localized  swellings.  In  the  ca^'e  of C 
alls,  such  as  the  Purkinje  cells  of  the  cerebellum,  the  are  b  Js  or 
|:cmnn,l,.s  to  be  seen  on  the  twigs  of  the  dendrites.  When  damage  has 
iH...  wrought  these  buds  may  be  seen  to  be  swollen,  and  to  be  2st  off 
.;  .  .sappear.  ^\e  suppose  that  such  swelling  of  the  nodules,  and  to  a 
sr  Iter  extent  such  castmg-off,  interferes  with  the  conductivitv  of  the 
.  .;l  s..  that  this  stat«^  of  the  dendrites  is  accompanied  by  impdrmeni 
"I  the  mental,  the  ,.  ,  .^ory,  and  the  motor  functions  Pa'^ment 

Pathological  Changes  in  the  Axone.-The  idea  which  is  most  wideh- 
nUerr,Hned  at  the  present  day  is  that  the  nerve-cell  bod  v  exe  ts  a  tronhic 
-  I—  ..P.m  the  entire  axone;  that  the  axone  maintains  it^ LtS, 
;  'ly  -hen  It  remains  connect'.^l  with  its  nerve-cell  bodv.  Cs  ' 
'"■■  nr  -.xune  be  cut,  that  part  of  it  which  is  separated  from  the  cort  ■ 
'  II  ..rth..  anterior  horn  c.ell  degenerates  and  dies,  and  if  a  sen  or^a'  „  ■ 
1".  ;  •".  the  part  separated  from  the  spinal  ganglion  ceil  uUima  • 
;;>'i..r.  aiKl  disappears.     Whatever  the  course^,f^he  aTo lu     Z  ■  e^ 

'"n=|  e  Its  relations  with  other  axones,  its  life  as  an  ax  m;     em,  ds 

-■;n  .ts  „e.r^e-cel   body,  and  if  it  be  separated  therefrom  i     s  u 

It.  iMtti  r>  .     i  he  one  wire  looks  like  the  other  ninety-nine,  but  no 


-IT 


l>.  th e  axone  in  a  short  time- twenty-four  hours-  shows  a 

■nu  "      he  myelin  sheath;  this  presently  becomes  changed  into  a 

-  "t  «  .i.ules  of  various  sizes,  of  a  fatty  nature,  which  S  mate  v 

'■XZ  %^j:;r'rl  <'5Kostion  and  absorption  by  the  c^l^'onil' 

.    hw..nn.        he  ..xis  cylinder  proper   becomes  irregularlv 

t.  I.  broken,  and  granular,  and  likewise  ultimatelv  disappears 

"I-'-  'H-'g  taken  by  proliferated  sheath  cells  an.l  fibrousS:' 


47,s 


TUK  SKRVOrS  SYSTEM 


m  t 


m 


a  rcplaceiiient  <Iesigiiate(l  hy  tlio  jiciu'ral  term  sclt-rosis.  Nor  is  <le- 
f;t'iierati(tn  luct'ssarily  coiifint'd  to  tin-  distal  ])art  of  tlie  axone;  it  may 
happen  that  the  parent  eell  dejrenerates,  apparently  from  laek  of  occu- 
pation, since  it  no  longer  can  transmit  messages  or  stimuli — disuse 
atrophy — and  such  atrophy  applies  alike  to  all  parts  of  the  neurone. 
Regeneration  of  a  severetl  axone  takes  j)lacc,  within  limits.  Where  a 
nerve  has  been  torn  apart,  the  injury  of  the  tearinj;  sometimes  extends 
a  short  distance  u])  tlie  nerve  trunk  toward  the  nerve-cell  body,  and 
may  be  followed  by  dej;eneration,  but  with  a  clean  cut  the  proximal 
end  (juickly  shows  re^'enerative  chanfjes  in  the  form  of  fine  ramifica- 
tions terminating  in  delicate  filaments,  the  axtme  itself  sejiarating  nito 
its  constituent  fil)rils,  some  of  which  terminate  in  a  little  cone  of 
growth.  The  central  end  of  the  axone  by  the  forward  movement  of 
the  fibril  referred  to  can  extend  from  the  point  of  section  and  join 
itself  to  the  distal  end,  i)rovided  there  be  not  too  great  an  intervening 
gap.  The  bridging  of  the  gap  betweei  . ''c  severed  ends  is  accomi)lished 
by  the  extension  of  the  ct-ntral  axone,  using  the  damaged  nerve  or  some 
other  tissue,  or  even  a  mechanical  insertion  as  a  scaffold,  ami  seeking 
the  course  of  the  destroyed  distal  axone  by  chemiotrojjism  or  attraction 
toward  tlie  sheath  cells  of  the  dcgeneratc(l  fibrils  of  the  <listal  part.  It 
is  evident  that  the  old  axis  c\  linder  undergoes  complete  degeneration, 
and  recovery  of  fimction  is  not  complete  until  the  new  axis  cylinder 
l)rocesses  have  tra\elled  down  the  old  shcalhs,  even  until  tliey  reach 
the  site  of  and  form  new  end-plates  in  the  muscle,  or  in  the  case  of 
sensory  nerves,  new  sensory  filaments  in  the  cud  organs. 

Such  gross  damage  as  we  have  been  considering  is  not  the  only  cause 
of  atrophy  and  liegeneration  of  the  axone,  for  there  are  at  least  two 
occasions  upon  wiiich  atrophy  can  occur  without  a  definite  interrui)tion 
to  the  continuity  of  the  perii)lieral  nerve.  Comparatively  mild  toxins 
acting  during  a  long  time,  esiu-cially  if  accompanied  by  fimctional  ac- 
tivity, ma>  diiniage  the  nerve-cell  body  to  an  extent,  slight  but  sufficient 
to  interfere  with  its  initriticm  as  a  whole.  Under  these  circumstances, 
the  most  outlying  part  of  the  neuront^  the  terminal  i)art  of  the  axone 
—suffers  most,  and  the  nutrition  which  did  not  sufHce  for  the  wliole 
neurone  may  suffice  for  the  neurone  minus  the  most  peripheral  ])art, 
which  is  thus  sacrificed  to  the  welfare  of  the  whole  neurone,  much  iis 
a  beleaguered  and  starved  city  might  save  itself  by  sacrificing  its  most 
outlying  garrison.  Where  the  peripheral  part  of  the  axone  begins 
to  atrophy  in  this  way,  we  may  predict  that  the  entire  neurone  will 
ultimately  share  the  same  fate.  A  second  kind  of  degeneration  is 
that  to  which  we  have  previously  referred  as  abiotrophy,  in  whicii,  l>.\ 
reason  of  some  congenital  lack  of  \  iiality,  the  stress  of  onlinary  neurone 
wo.  k  is  too  great,  and  the  structure  atroi)hies  under  *'mulus  tluit 
would  not  ilamage  a  healthy  neurone;  such  a  neuroiu' '  .  a.   '  .-^pt  nds 

its  life  with  so  little  spare  energy  at  its  disjjosal,  t,        ;1k,  ...dinary 
expenditure  of  eni./v  is  too  great  for  it  and  it  atrophies  j.eniaturely. 

Lesions  of  the  neurone  may  be  accomi)anied  by  a  great  variety  of 


GESKRAL  niSrCRBAXCKS  OF   THE  SEKVOIS  SYSTK.Xf     470 

-.npt.m.s,  and  these  it  is  not  pcssiblo  to  particularize,  co,npri.sinK. 
;':,'"■>;'•''  !*"  ^^""'V»^  *'*f"»te  iiml  imiefinite  aberrations  of  function 
(I  rlie  .iehnite  tunet.ons  possessed  by  the  neurone  we  are  able  to  note 
tli.it  ! ,  tlie  stnnuh  which  excite  muscular  contraction  mav  be  absent 
nr  u.ak  or,  if  present,  inefficient,  so  that  the  muscle  rests  in  a  state  of 
partial  or  complete  paralysis;  (2)  or.  contrariwise,  the  stimuli  mav  be  so 
tr..,n,.nt  or  so  extreme  as  to  excite  a  <lisordered  and  too  great  activity 
ot  th..  muscle.  1  hese  changes  in  the  state  of  the  nerve  ma^■  be  corrt- 
lilted  with  an  actual  les.on  which  we  can  see;  but  it  mav  "not  be  so, 
nii.l  i.Itliongh  the  two  states  are  widely  .liferent  from  one" another  we 
iMM.y  not  be  able  to  distinguish  any  .liHVrence  in  the  nc-one,  nor  may 
w  t.e  able  to  tell  that  it  is  actually  the  neurone  that  is  at  fault.     If  we 

:."'■  ""  1':'^ "«'^''»'  f^l'»"Ki'  '"  «iich  a  neurone,  we  sav  that  the  fault 

li<-  not  m  any  organic  alteration  of  the  neurone  but  in  its  function 
>iMd  we  .jcscnbe  such  alterations  of  the  normal   performance  of  the 
organs  as  functional.     It  is  not  ,)ossible  to  say  that  functional  diseases 
''..-called)  are  attende<    by  no  ..rganic  change  in  the  neurones;  all  we 
<.iti  say  is,  tiiat  it  ther.-  be  change,  it  is  not  to  be  detected  bv  our  present 

Similarly  in^  the  sensory  neurone  whose  iini)ulses  pass  from  the  per- 
ipiMTv  „t  the  bo,  y  to  the  nervous  system  we  find  that  certain  lesions 
'•  lii'  .uMiruMc  destn^y  the  conducting  power  completelv;  or,  again, 
"ith  MO  visible  alteration,  we  discover  that  the  ft.nction  of  the  sensorN- 
'H  nrone  is  altere.l  or  abst-iit-  that,  like  a  ba.lly  manned  telegraph  line 
>  H  r,'  „,ay  b,.  n.  messages  at  all  (anesthesia),  that  the  message  initiated 
■I'  the  skin  max  be  exaggerated  (hyperesthesia),  or  mav  be  entirely 
P^ir,,i.|,rase.lfrom  its  true  meaning  (paresthesia).  To  make  the  matter 
'n-rr  .,,„t,.sing.  any  of  these  deviations  from  the  true  function  of  the 
-nn„M.  may  not  be  due  to  inefficiency  of  the  neurone  at  all,  but  mav 
;■'  in.ntal,  just  as  the  messages  taken  by  a  bad  receiver  from  a  good 
;'  -  u'-.q.l.  „„.  might  seem  to  in.licate  that  the  line  itself  was  inefficU-iit 

-  ^N.n  ot  all  this  ,s  that  there  is  little  known  about  the  organic  changes 
'    I'^'I'Ih;"   .11   the  neurone;  that  wi.erever  we  observe  disordere.l 

";"-'  -ithout  a  correlate<l  lesion,  we  call  the  (lisorder /^o.dlw 

• '    M.,„y  disorders,  today  called  functional,  may  prove  ultimately 

■   "■  to  organic  change;   and   that  a  knowledge  of  the  highest 

I"  ■   "■"  "t  the  nerve-cell  body,  even  thought  itself,  is,  as  yet,  a  cLed 

GENERAL  DISTURBANCES  OF  THE  NERVOUS  SYSTEM 

lt|'tnn.  ,.r,„,,,ling  to  the  consideration  of  the  organic  changes  found 

:^    .    mnous  system,  ,t  ,s  necessary  to  discuss  briefly  some  of  the 

'  '*    M.e„  m  ,t  winch  are  m,t  referable  to  a  definite  cell,  or  a 

n  ,  .'•'■  ■''  '^''""'  P^"P^^^^'  ""vc,  but  see.,,  to  involve  a  large 

;   ' ;  t  ti.e  entire  system  or  at  least  a  very  important  part  of  it;  such 

■'■     ''"inni.  convulsions;  Hiul  coma.  '  'i,  sucn 


»fmmm 


480 


THE  NERVOUS  SYSTEM 


_  Delmum.  -Delirium  is  an  affection  of  the  mental  function,  in  wh 
judgment  and  the  appreciation  of  the  relations  of  surroundings  to  c 
another  or  of  the  patient  to  surroundings  is  impaired  The  spec 
senses  may  or  may  not  be  (lulled,  hut,  at  the  best,  understanding  of  i 
messages  they  convey  is  obscured,  and  misinterpreted.  The  degr 
of  mental  confusion  vary  widely;  delirium  mav  be  the  dangerous  fi 
of  the  maniac,  the  meaningless  shouting  of  the  terrified  but  half-uncc 
scious  drunkard,  or  it  may  be  the  disordered  dreams  of  the  quiet,  febr 
patient,  whose  mind  wearies  iiself  by  hearing  the  fancied  rattle  ol 
machine  or  by  the  ceaseless  repetition  of  some  imaginary  task  or  volt 
tary  action.  Active  as  the  mind  seems  to  be,  and  great'as  is  the  expc 
diture  ot  energy,  there  is  usually  a  corresponding  dulling  of  conscioi 
ness  m  some  other  direction;  there  is  at  times  physical  activity 
great  as  to  require  restraint,  or  the  muscular  activity  may  be  rediic 
merely  to  picking  at  the  bedclothes,  subsultus  tendinum  (a  voluntary  a 
misdirected) ,  or  there  may  be  visible  only  a  tremor. 

Delirium  is  often  an  accompaniment  of  the  pyrexia  of  the  vario 
intective  fevers,  typhoid,  typhus,  smallpox,  pneumonia,  and  rheumatisr 
but  IS  rather  a  manifestation  of  the  presence  of  a  toxin  than  a  me 
accompaniment  of  hyperpyrexia.  Delirium  tremens  is  an  example  of  ti 
ettect  ot  an  unaided  chemical  poison;  the  delirium  of  a  child  in  pnei 
monia  represents  that  arising  wholly  from  an  infective  agent  and  i 
toxins;  the  delirium  of  ac-iite  mania  is  an  instance  of  that  form  whic 
arises  in  the  brain  without  a  known  physical  cause— and  the  diversif 
of  these  forms  indicates  how  hopeless  a  task  it  would  be  to  define  th 
anection  in  any  patiiological  sense. 

Coma.— Coma  is  a  state  of  unconsciousness,  and  represents  not  s 
much  an  actual  derangement  of  the  function  of  the  lower  nervou 
system  as  a  state  in  which  there  is  an  arrest  of  the  highest,  the  mentr 
.unctions;  the  contro'  which  mentality  exerts  on  the  lower  nervou 
system  is  lessened  or  absent.  Thought,  perception,  volition,  and  volun 
tary  movements  are  in  abeyance;  if  the  coma  be  not  of  the  deepest 
reflex  m(.veinents  can  be  instituted,  but  the  muscles  are  relaxed;  th 
centres,  such  as  the  respiratory  and  circulatory,  which  are  automatic 
are  depressed  in  their  activity,  but  their  functions  are  by  no  mean 
abciiished.  (  onciission,  pressure,  exhaustion  from  previous  excitation 
and  toxins  appear  to  be  effective  causes  of  this  state. 

Convulsions.— A  convulsion  is  a  series  of  involuntary  contraction; 
of  the  muscles;  if  only  a  few  muscles  are  concerned  or  only  a  siiifjlt 
part  c)f  the  body,  the  term  spasm  is  usually  applied,  while  the  tern; 
convulsion  is  used  to  describe  the  phenomenon  occurring  in  all  or  manv 
parts  of  the  body  together.  (  onsciousness  mav  or  mav  not  be  lost :  tfi't 
convulsion  in  any  case  is  quite  apart  from  the  action  of  the  will.  Let 
the  reader  think  for  a  moment  of  a  motor  nerve  cell  with  its  axone  and 
the  muscle  supi)lied  by  it;  voluntarily,  he  mav  send  a  stimulus  to  tlie 
muscle  (;um\  ecrtain  of  its  rieighliors).  The  message  calling  for  muscu- 
lar movement  goes  down  the  wire,  the  axone,  and  as  a  result  the  muscle 


^W^ 


'^■ 


.^[■"ip^^m^^  W" 


TOXUS 


481 


('..iitracts.  It  is  as  if  the  muscle  were  a  marionette  that  performs 
whin  tlie  wire  is  pulled.  In  diseased  conditions  misdirected  stimuli 
uuiy  (onie  to  the  nerve  cells  from  various  sources  and  these  stimuli 
may  produce  disordered  purposeless  muscular  movements.  To  follow 
our  simile,  it  is  as  if  a  mischievous  boy  found  his  way  to  the  keyboard 
wliicli  controls  the  marionettes;  instead  of  pressing  them  in  their  proper 
(inKr  so  as  to  produce  coordinated  action  of  the  marionettes,  he  does 
Ins  l)pst  to  make  them  all  work  at  once,  and  the  figures  dance  in  a  hope- 
less disorder.  In  the  brain,  it  may  be  a  toxin  which  irritates,  or  it 
may  be  a  near-by  tumor,  or  a  clot  of  blood  which  presses  the  brain 
(ills  -m  any  case,  like  the  boy  with  the  wires  of  the  marionettes,  the 
irritant  plays  upon  the  nerve  cells:  they  send  out  impulses  and  the 
iiiiiscl(  s  dance. 

Tins  leads  us  to  say  here  a  few  words  regarding  the  normal  tonus 
or  |)iiysiological  state  of  the  muscle  and  the  significance  of  exaltation 
iiiKJ  .icpression  of  the  same.     All  the  cells  in  the  body  may  be  said  to 
liii\  e  an  mtrmsic  tone,  but  in  the  --'untary  muscles  it  is  clear  that  we 
(  eal  with  more  than  this,  fur  if  th^  ..erve  going  to  a  muscle  be  divided, 
the  muscle  nnmediately  passes  into  a  flaccid  state;  or  otherwise,  stimuli 
arc  constantly  passing  down  the  nerve  from  the  central  nervous  svstem, 
wliich  stimuli  without  any  act  of  the  consciousness  or  will,  maintain 
tlic  muscle  fibres  in  a  condition  of  relative  partial  contraction.    The 
next  (lucstion  is,  what  is  the  nature  of  these  stimuli?     Is  it  a  constant 
"iitflow  or  does  the  tonus  of  the  muscle  represent  the  summation  of 
IhtkhIic  and  rapidly  repeated  impulses?    The  delicate  string  galvano- 
iM.  t.T  applied  to  motor  nerves  informs  us  that  the  latter  is  the  correct 
■ni>\MT:  that,  in  health,  each  voluntary  muscle  receives  stimuli  reaching 
If  -n  tlic  rate  of  from  five  to  fifty  per  second.    These  stimuli  are  minimal 
I'iir  -Mfhcient  to  set  m  action  those  associative  and  disso.'iative  processes 
^vliK  h  l.ad  to  contraction.     When  the  neurone  is  fatigued,  the  rhvthm 
~"  tiis  to  l,e  slowed,  and  apparently  the  rate  of  rhythm  in  coorc.  .lated 
iMUMlcs  IS  subject  to  variation,  that  is,  may  not  be  the  same  for  the 
liA.,rs  an.  the  extensors  respectively;  in  this  wav  we  mav  explain  the 
reniors  (4  cases  of  nerve  exhaustion  as  flue  to  a  lack  of  correspondence 
I"  tN\.,n  the  rates  of  contraction  of  the  flexors  and  the  extensors  of  a 
I'.in.     Ihis  tonus  then  is  a  "state  of  preparedness"  of  a  muscle;  the 
'I'ti'r.iue  between  tonus  and  voluntary  contraction  is  a  matter  of 
'I'  -r, ,     1,1  a  normal  contraction  there  is  not  a  single  impulse  but  a  like 
~'n,.  „|  rliythniic,  rapidly  recurring  stimuli,  apparentlv  at  the  same 

a^  hut  individually  stronger  than  those  necessarv  to  produce 

'reserve  tonus. 

"  'lescribing  convulsive  movements  of  the  muscles,  it  is  usual  to 
nniruish  tonic  and  clonic  contractions;  in  the  former  the  stimuli 
I'r  M.  ra])Kliy  that  the  proper  time  of  relaxation  is  not  granted  to  the 
'  ':■  iincl  a  continuance  of  the  contracted  state  happens-  tetanic 
"  'ontraction;  in  the  latter  either  by  partial  tiring  of  the  muscle 
'.■I  less  rapid  series  of  stimuli,  the  muscle  goes  alternately  into 


rate 

;ni,| 


til 


4.S2 


TIIK  M':i{\()rs  SYSTKM 


m  ' 


tlif  oni.tracted  jind  tlic  nlaxed  stiiU-  rh,„lc  contractions  Tlie  te 
cIonuB.  hy  nsaKc.  has  coin.-  to  i.avt;  a  slightly  (lifr.-rcnt  sisnifican 
by  clonus  wc  nu-an  tlic  plicnon.cnon  associated  with  tendon  or  mus 
reflexes,  wf.ere  in  places  of  yetting  a  single  response  to  a  tap  or  n 
upon  a  tendon  there  is  ehcited  a  recurrent  series  of  contractions  d 
to  conditions  causing  exaggerated  muscle  tonus.  ' 

The  part  atrected  hy  a  convulsion  may  enahie  tlu-  observer  to  defi 

the  site  ot  tile  lesion,  especially  if  it  be  situated  upon  the  cerebi 

cortex;  here  the  ceils  of  only  one  group  or  a  few  groups  of  muscl 

may  he  atlected,  in  which  case  the  convulsion  is  called  focal  or  Jac 

ioman  (Ilughhngs  Jackson  having  first  described  it).      Even  if  t 

lesion  be  strictly  localized,  it  sometimes  .seems  as  if  the  excitation 

the  cells  imm.'diatclx-  affected  could  sprea.l  to  others,  in  ever-widenii 

circli-s    new  cells  being  involved  succ.-ssively,  so  that  the  convulsi. 

extends  in  that  half  of  the  body  first  affected,  in  a  definite  order      Co 

yulsions  are  classified  nccording  to  their  origin,  rather  according 

their  sup,.osed  origin,  for  most  of  such  a  classification  is  pure  conjectur 

t  le  difficulty  of  determining  the  <aiise  of  convulsions  is  enhanced  I 

tlie  .lifferenccs  of  irritability  of  the  nerve  cells,  not  only  in  difl-erei 

persons,  but  in  the  same  jjerson  at  ditferent  periods.     .Xevcrtheless 

is  customary  to  sa>-  that  the  causes  of  convulsions  are  (1)  mechanica 

as  when  a  tumor  or  hemorrhage  in  the  skull  causes  extra  pressure  up.. 

the  motor  nerve  cells,  or  (2)  toxic,  as  in  alcoholism,  uremia  or  lea 

poisoning,  (.,)  reflex,  e. ;,.,  some  cases  of  epilepsy,  as  when  an  inflamniii 

turn  or  irritation  in  some  .listant  part  of  the  body  (perhaps  even  pin 

worms)  appears  to  be  the  cause,  or  (4)  functional,  when  the  stimiihi 

appears  to  originate  in  the  highest  cerebral  cells,  that  is,  the  cells  con 

earned  with  th..ught  and  association.     Stimuli  of  this  sort  are  calle. 

ideogenous. 

Focal  or  Local  Changes  and  Their  Resu.\s.-I)istinct  from  the  state 
just  dLscussed  whieh  concern  the  most  important  parts  of  the  nervoui 
s.vstem  an<l  through  them  affect  the  entire  system,  are  those  chanu'c: 
which  remain  limited  to  a  part  of  the  system,  which  are  thus  call.-. 
focal  or  ocal.  \\  ..ere  changes an«  cxideiiced  by  symptoms  which  poinl 
to  the  destruction  or  damaging  of  a  neurone  era  set  of  neurones 
whetlier  the  damage  be  wrought  in  the  nerve-cell  bodv,  the  dendrites, 
or  the  axone,  whether  the  neurone  be  motor,  sensorv,"or  sympathetic, 
any  sufficient  lesion  in  any  part  of  it  will  be  shown 'bv  a  failure  in  its 
function  -thus  a  muscle  is  paralyzed  or  is  weak,  sensations  are  not 
carried,  or  are  carried  incorrectly  (paresthesia).  The  symptoms  pro- 
duced arc  thus  dependent  upr  -i  the  nerve  centre  or  the  nerve  path  tliat 
IS  concerned,  although  it  is  of  course  to  be  remembered  thnt  ^he  ner- 
vous mechanism  may  be  intact  and  fully  operative  ami  a  parahsis, 
tor  example,  be  <liie  to  some  fault  of  the  muscle  or  other  structure  ( oii- 
cerned  in  the  performance  of  motion. 

Focal  Symptoms  in  the  Field  of  Motor  Nerves.— From  the  raomont 
at  which  the  student  begins  to  study  focal  symptoms,  he  requires  an 


:'SrmH^,,  ;•  m^^'v  '-~^;^w^'^'^^:mm^'mic  '^.r 


FOCAL  LKS/nxs 


4.S3 


|i. .  iirafr  km.wlr.lp.  „f  the  sit.intinn  of  the  various  groups  of  i.erve-oell 
I.O.IHS  ,„  tlu-  l.nnn  and  conl  an.l.  of  conrse.  of  tl.e  axor.es  from  these 
j:nm,,>.     l{..tw,.,.„  the  e,.rtual  cell  an.l  the  muscle  two  neurones  run- 
h.'  upper  mul  the    mver  mot..r  neuron...    The  upper  motor  neurone 
liiis  .t>  c,H   uhIv  in    he  cortex,  an.l  its  me.lullate.l  ax..ne  crosses  to  the 
opiMMt..  sKle  ami  there  runs  with  other  m..tor  n.-rves.  especially  in 
tl:.'  .•rnss,.<l  pyrami.la   tract,  to  reach  the  nerve-c.>ll  h.i,|v  .,f  the  l/.wer 
.iH.for  ...ur..,,,^.  wh..-h  ,s  situatnl  in  the  anterior  horn^  ..f  the  conl. 
In.n.  the  .rll  ho.ly  ,n  the  horn  the  ax.,ne  .  f  this  secon.l  cell  run-  by  a 
I..npl,..ral  >';;ry|".to  the  muscle.     If  the  ,,eripheral  nerve  he  cut  near 
til.'  .nnsd,.  all  this  elaborate  mechanism  is  rendere,l  temp.,rarily  u.seless 
^o  h.r  M-  the  muscle  is  concerne.l,  an.l  the  muscle  is  paralyzed;  if  the 
npi-cr  n,  tor  n.;uron,'  just  below  the  c.rtical  nerve-cell  bmly  be  cut 
tiM'  nn.^    ..  >s  similarly  paralyze.1;  how  can  one  tell  in  which  of  thes; 
>i  nations  ,s  the  actual  lesu.ny    Th.-  nutrition  of  the  muscle  depen.ls 
lit mi.it.'ly  up.,..  Its  ...miection  with  the  nerve-cell  [hhW  of  the  lower 
.1.  or  m.„ro.,e;  ,t  the  l.,wer  motor  „e«ro,.e  be  intact,  nutrition  is  not 

rx  -,..li  h.,.|y  of  the  lower  motor  neurone  chooses  to  sen.l;  and  if 
ti.'  l.s,o„  Ik-  ,.,  the  upper  motor  .leurone.  the  cortical  cell  body  has  no 
^.^  <rnn,Hr  ov.-r  t  he  h.wer  cell  b.„ly  and  the  latter  "breaks  loose''  semling 
•n.iu.nt.  i.n.a  Ic,l-f„r  stimuli  to  the  muscle,  which  is  thrown  into  a 
;  ;|  .  .  ,..,tai,,|,ty  (hypertonus)  and.  it  may  be.  spasm.  On  the  con- 
':,,•,  ,"■  ,  ^^^rxtln-knuT  motor  neurone,  no  impulses  at  all 
'^'l^^^;;.^^-^   -  >|H'rt.  flacci.l,  hypotonic..  a...l.  cut  off  from 

>"n  -(.•  I  body,  quickly  deRcerates  an.l  atn.phies.     To  recapitu- 

Y','lr><fr>uium  of  the  vpper  nwior  veuroue  allows  h,periomis  orTm^m 

;;;«..;..   jA^..r.c.-o„   ofthe  loreer  nroior  .Jol,  Mcidit'JZd 

■  7.    ;.d.        1         ".'""t,'-'"  ""    *'"  "•'  ^^•'"■^'^  P"t  "f  the  tract  is 

tr  X  d.  t ,  .l,.term.ne  th.s  requires  consi.leration  .,f  all  the  facts  in 

I'    -   -.Much  can  be  learned  from  the  extent  of  the  damaffe-  if  we 

-    r  tl,,  ,„         „„  tor  neurone,  it  will  be  apparent  that  f  lesio. 

"•I'  a>  iKniorrhaK-e.  tluKiRli  .,f  small  size,  might  affect  a  great  mTnv 

I  l.a..ke,l  cl..sely  together,  as  in  the  internal  capsule.     A 

trn  ,  ,     I  •  ■    ^^'""'"'•ly,  in  the  lower  motor  neurone   a  .1.- 

l-v<    I  vher  .?  '\"''.P"*;'"t  "f  ^^rvice  m.,st  of  the  muscles  of  a 

„r  ,;„;' 'iV;.  ''"^^'""^-h"'"'  ^^"«.  «"<i  put  ..ut  of  servi..e  only  a  small  gn.up 

'-'''n?.v'beT^tic'^*'*''^''''fY'*"*'^^•--^^'«  -^'  tJ^-'  tl-t  a 
^      l.',^  l)e  imretic  or  paralyzed  by  reas..,.  of  some  disease  in  the 

■  .r  m  wi;.-!"!  '"•"■'  ^"""'""Iv..  by  reason  of  some  disturbance  in 
s   "I    i  ':!:7^:^^^^^^^  >-*  -^-ther  way  in  which  the  same 


n-MJt  is 


T>r.i,ln^,  I       J  ii  ■'."."•'^'^"'"'^"*^'"»yinwmcn  the  same 
produced,  and  that  is  m  the  so-calle.l  hysterical  paralysis;  here 


V«^^ 


4.S4 


THE  SKHVOl  S  SYSTEM 


the   musle   is   htvilthy,  the   neurone   intiiet,  l)ut  the  niiiseh'  is  i 
stimulated  by  its  neurone,  whose  action  is  inhibited  l)y  tl"  mind  « 
in  other  words,  by  some  Rroup  or  proujjs  of  eclis  which  are  eoneern«' 
with  the  mental  functions,  and  are  the  i!nilti|)h'  K"verning  power  i 
the  brain. 

Hitherto  we  have  spohcen  f)f  lesions  of  tiie  neurones,  evidenced  b 
paralysis  or  paresis  of  the  nusch-s,  that  are  (hie  to  prevention  or  (h 
pression  of  the  function  of  ti  e  neurone  -the  so-caMed  depressive  mani 
festatlons,  l)nt  there  is  another  form  of  lesion,  the  irritative.  Hefor 
pointing  out  what  these  are,  it  may  be  said  that  a  lesion  can  destro; 
some  part  of  the  neurone,  so  that  stimuli  from  that  neurone  ceas 
entirely;  or  the  lesion  may  merely  interfere  with  the  stimulus,  whici 
reaches  the  muscle  in  a  weakened  degree;  or  the  pressure  of  the  lesioi 
may  act  as  an  irritant  to  the  neurone  so  that  it  is  stimulated.  Heini 
stimulated  in  a  wrong  way  and  from  a  wrong  source,  the  messages  i 
sends  to  the  nuiscle  are  certain  to  be  ill-time<l  and  purposeless,  because 
they  are  not  instituted  by  the  mind,  as  part  of  the  properly  coordinate! 
plan  of  stimuli  in  obedience  to  which  the  proper  muscular  work  t)f  th^ 
body  is  carried  on.  These  irritative  lesions  are  important,  and  will  b 
particularized;  the  signs  by  which  the\  are  accompanied  are  tremors 
choreiform  movements,  conciihions,  and  the  muscular  activities  tha 
result  in  contractures. 

Tremor. — ^^Fremor  is  a  series  of  consecutive  "small"  muscular  move 
ments,  and  is  familiar  to  everyone  a;,  se-.n  in  some  of  the  very  old 
The  tremulous  mf)vement  in  difl'ercnt  people  may  vary  greatly  in  it: 
rapidity  and  in  its  situation,  being  general  or  limited  to  one  or  sevcra 
groups  of  nniscK-s.  Tremor  usually  ceases  during  sleep;  sometimes  it  i: 
lessened  or  i)revented  temporarily  by  the  exercise  of  the  will;  in  othei 
cj;  OS  it  is  seen  only  when  some  voluntary  movement  of  the  part  i: 
le  (intention  tremor) ,  in  yet  others,  during  rest.  A  form  of  movemeni 
cl()sel>-  related  to  tremor  is  fibrillary  tmtching  of  the  nniscle,  in  whici 
the  individual  muscle  bundles  are  seen  through  the  skin  to  contraci 
(|uickly  and  rhythinicalix-.  Tremors  are  readily  observed  in  sonit 
alcoholics,  in  paralysis  agitans,  in  multiple  sclerosis,  in  lead  poisoning 
and  many  other  states.  We  have  already  referred  to  the  mode  of  pro' 
duction  of  muscular  tone  (p.  47.")).  If  the  rate  of  these  tonic  impulses 
to  two  sets  of  antagonistic  muscles  l)e  different  it  will  be  seen  that  thert 
will  be  a  lack  of  synchronism  between  the  respective  contractions  oi 
the  two  sets,  so  that  the  liml)  or  part  affected  is  drawn  momentaril\ 
now  in  one,  now  in  the  other  direction. 

Choreiform  Movements,  -("horeiform  movements  ar'»  of  the  natiiro 
of  intermittent  clonic  spasms;  tiiey  appear  as  irreguLi,  purposeless, 
jerky  motions  of  the  limbs,  face,  or  body,  and  are  seen  in  chorea, 
Huntingdon's  chorea,  spasmodic  wry-neck,  tic,  and  hysteria. 

Convulsions. — Convulsions  have  been  already  considend  (seep     '•O'l- 

Contractiire. — These  are  the  states  of  body  in  which  the  ni  -ility 
of  the  limbs  is  lessened,  and  the  position  assumed  by  a  limb  is  gradually 


Jt' 


Y^TT 


THE  BRAIX 


48/) 


fiv.l.  so  that  It  cannot  be  movo.1  from  that  position.  This  occurs  in 
two  « ays  ^  a  unh,  for  example,  n.ay  he  f1exe,l  l,y  the  activityTflexo; 
nn-Mles  whuh  are  continually  in  a  state  of  spasm,  rr  by  the  action  of 
n..nK.l  flexors.  unopjMKm!  by  extensors.  In-cause  the  latter  are  paralvze.1 
uli.lr  the  former  st.  I  remve  the  normal  tonic  impulses.  This  laui 
tnrin  ot  contracture  IS  termed  passive. 


THE  BSAIN 

Gross  Anomalies  -These  may  be  .livi.led  in  the  first  place  into 

I)  those ussoe.ttted  with  inaliormation  of  the  vault  of  the  skull,  which 

v.-  .nay  call  cranial  anomalies,  and  in  the  second  place.  (B)  thos^  of  the 

l.nm,  alone,  the  cranial  vault  being  intact.  »«oirne 

(jl )  Of  tlie  former  we  have  a  remarkable  series,  associated  evidently 

«  th  nnperect  closure  of  the  dorsal  groove  in  the  region  of  the  cephal  c 

lol..s  .Ihistrating  all  stages  in  which  this  is  either  partial  or  complete 

or  a,ro,npan.ed  by  a  greater  or  less  extent  of  imperfect  closure  of  the 

^o  natu-  dorsal  groove  (spina  bifida).     AnencephJiy  or  acrania  is  that 

Is''.').?"'',  '^rV"  •"""'P'"*"  ^'^'''  °^  '^'  ^""'t  «f  the  skull  and  o 

n      '  Vr        I  ^'•«'";^,^r*'-'nt«i  by  a  mass  of  congested  mem- 

.u„>.     II  ebasal  part  of  the  brain  is  present  and  gives  origin  to  the  eye 

th.'  ear.  and  the  cranial  nerves.     In  exencephaly  the  defective  deVeK 

"-t  .s  partial;  the  vault  of  the  skull  is  in  part  develop^ I,  most  fr^ 

n  ly  t^^^^^^^  frontal  rc,;on;  there  is  imperfectly  formed  brain  substance 

h,  1    nerl  angs.  like  a  sack,  the  back  of  the  neck,  or  in  other  cases! 

My  MS.    As  a  result  of  amniotic  adhesions,  the  projecting  part  mav 

Ix'  lat.ral  and  unsymmetrical.  i     J       "fe  par.  may 

r...lf  rk!.hl™''^"™"""'^  "^  ^^'  ''™'"  ^'""^'  *^^  f""°«'"g  "«  the  most 

«n  GeneraL-Microcephaly,  in  the  typical  form  of  which  the  whole 
•  l.ram  ,s  small  and  poorly  .levelope.1,  the  cranium,  while  pe  S 
li.'  .orrespondingly  small.     The  brain,  instead   of  weighing    OQO 

;  :."'  '"T  ^■"^'^  -^!'  ^'-^T^  ""•  ^'''-    ^^^^'  '^""dition  is  assoda^  S 
"li'Tx,  and  IS  sometimes  familial. 

nn'ir w.^lf '^  ■;,  «  T'^'^'T  "*■  "^•'*"'"**'  '■"^■••^"^^  '"  '^f«'n  substance. 
■r^ .  1  M    ^^,.||  uuthenfajted.    Some,  but  not  all  of  the  greatest  men  in 

^'0    ;■;;;;;'  '";;    "f  ^^f  r-  -tal>lv  Oomwell  and  Bismarck  (ov  r 

J^\u^!t7  'P'T.u'^l  ^^^.P\^'^'  microcephaly,  the  cerebellum  being 
.■'   doped  and  the  hemispheres  of  small  size  and  with  poor  convi 

'  ■  ^mZJ^T  ^"^r  V-^  "^"i'''^'^  development  of  por^on" 
l.rM  'it.h,  ?tKv-  P.  Tj=  °  ^^''  ^^'  '"'^^^  characteristic  form  is 
'  -     H   or       r^,r^T        f  r'^P'^f  "t  °^  ^y  i»tru-uterine  obstruction 

/e  the   in  r  1  *'"  'V'*':""  ""^'^^'^^  ^""^^y-    As  a  result 

^  iitlur  in  the  early  stages  a  lack  of  development  or  in  later  foetal 


lii!  re  is 


l.H(i 


TiiK  xKinnrs  sysrhwr 


1-3  f 


I: 


or  early  |K)stimtal  life  absorption  of  the  ana  supplie.!  hv  that  vesse 
witli,  111  eoii.se. i.un.T.  the  formation  .,f  a  evst-like  spa<'e  ...vereil  h 
the  iiieinhraiies.  eontaiinii«  <rrel.rospiiial  Hiii<l  (porencephaly)  .M„r 
rarely  .lefinit.-  portions  of  tlu-  l.n.in.  snel.  as  the  eorpns  eallosnin  ma' 
l)e  iimlevelope.1  an.l  wantiiiij.  A  slighter  .l.feet  is  heterotopi*.  in  whicl 
IM>rtioiKS  of  the  Kray  matter  are  aU-rrant  an.l  are  f.Min.l  in  the  whit, 
matter. 

There  is  e..nsi,leiahl.-  variation  t..  !«■  foiin.l  in  the  .levelopnient  an. 
numher  of  the  c.)nv..lnti..ns;  in  s..-.alle.l  degenerate.,  these  mav  Ix 
re.lnee.l  in  number  an.l  shallow,  from  flatteniiiK  of  the  Rvri  (a»^a) 
In  those  of  hiKh  mental  .levelopinent  they  are  f.,nn.l  we'll  .K.vel..WMi 
and  abundant.  ' 

Circulatory  Disturbances.    Anemia.    The  brain  is  f..nn.l  strikindv 
)h)o,IK.ss,  and  of  almost  milky  white  e.,l.,r  in  eases  of  .k-ath  fn.in 
hem.)rrhaKe.  as  aj,'am  m  eases  ..f  profonn.l  systemie  anemias. 

Hyperemia.  Hyperemia  of  th.-  passive  onler  is  seen  in  eases  of  chronic 
general  oonKe.stion,  as  in  canliae  .lisease,  of  obstruction  to  the  ven.M.s 
outHow  by  way  ot  the  jugular  wins,  as  in  hanging,  and  in  eases  of  sutfo- 
eation  or  death  in  convulsions.  The  brain  oozes  more  blcxxl  than  usual 
on  section  an.l  the  cut  vessels  are  m..re  than  usuallv  prominent.  Active 
hyperemia  is  seen  in  cerebritis,  an.l  in  such  states  as  mania,  delirium 
tremens,  and  to  .some  extent  in  ca.ses  of  .leath  at  the  height  of  acute 
infections  As  in  c..ngesti.)n,  .s«.  als.,  in  (edema,  the  condition  is  best 
recgnize.!  by  the  state  of  the  membranes;  cen-bral  oedema  is  reog- 
ni/able  by  the  pah'  v  vt,  m:<]  shii.v  i;rfuce  on  section.  (Kdema  mav  !,,. 
extreme  m  the  vicinity  of  a  new  gn.wth,  the  infiltrate.1  brain  tissu.- 
appearing  actually  gelatin..us.  The  cau.ses  of  oedema  in  general  are 
those  .)t  extreme  passive  congestion. 

Hydrocephalus.— IIy<lr.)cephalus  is  of  two  orders— external,  where 
the  excess  .,f  flui.l  is  outside  the  brain  (see  meninges),  an.l  internal, 
wfiere  the  accumulati.)n  is  in  the  ventricles.     The  latter  is  the  more 
striking   and  may  be  ac(|uire.l  .luring  intra-uterine  or  postnatal  exist- 
ence.    Ihe  on.lition  is  progressive  and  the  head  mav  attain  an  extra- 
ordinary size,  the  cranial  bones  becoming  «s  thin  as  paper,  or  even 
replacci  by  m.-nibrane  and  wi.lely  separated.     Through  the  unusual 
.listensic-n  of  tlu-  ventricles  the  brain  substance  becomes  thinne.1  to 
an  almost  incrclible  .legree.     There  is  still  debate  as  to  the  cause,  but 
even  if  m  the  hrst  stages  there  is  extensive  formation  of  cerebrospinal 
f^ui.i  from  ependynial  irritation,  etc.,  the  main  .listurbance  in  a  fulh 
de\  el.)ped  case  is  .)bstruction  t.)  the  outflow  of  the  fluid  from  the  veil- 
tricles  into  the  system  of  meningeal  spaces,  -ind  so  into  the  lymphatics. 
Hydrocephalus  of  the  fourth  ccntricle  is  rarer,  but  occurs  as  a  result 
ol  obstruction  m  the  lateral  recesses  in  which  run  the  choroid  plexu.ses 
and  which  communicate  with  the  subarachnoid  space. 

Hemorrhage.— Hemorrhages  of  the  small  vessels  of  the  brain  niiiv 
occur  in  larirc  number  and  of  HmnU  -^ixc,  from  trauma,  especially  iii 
concussive  injuries  an.l  at  the  site  atlecte.1  by  "contrecoup."     Thev 


^^^3 


rilK  HUMS' 


4.s; 


,irr  >..,..,  nnir  the  hutUhv  <m  swctio.i  of  tlio  brain  siibstunre.     Urge 
_M  .iH.rrluiK's  in  tlu-i-  n-pons  an-  ran  .  apart  fn.ni  actual  iHccrution 
I,;irt.v  lMni..rrl.aK,'s.  Ii.,wrv,.r.  inav  o<-,nr.  nctal.ly  .Itrp  in  tlu-  substance 
..I  tl.r  h.-misplu r.-.  inv.lvinK  tlu-  internal  .•a,)snl...  ,.,r|.us  striatum,  ami 
(.plir  tlmlarnus,  li-ss  rarrly  in  the  pons  and  base  of  the  brain       These 
iir.  ult.ii  ol  lar^e  size,  as  nni,-h  as  several  ounces  of  blooil  iM-iiiKeffuse.! 
with  «nat  acoinpanyiiiK  .lestruction  of  the  brain  tissue;  the  blixNl  niav 
.•...|„.  into  the  ventricles.      Why  this  shonhl  be  the  seat  of  election 
tc.r  .rrc  .ral  lieinorrhaKe  a|)p.ars  to  be  <lu<-  to  the  fact  that  the  lenticul.H 
>trii,tr  branches  of  the  mi.l.lle  cerebral  are  almost  in  a  direct  line  with 
t hr  internal  caroti.l  and  thus  are  subjecte.1  to  the  Rreatest  f..rce  of  the 
I.I'hhI  stream.     From  their  position  such  henurrhaKes  are  likelv  to 
.n\..lvc  the  anterior  two-thirds  of  the  posterior  limb  <,f  the  internal 
<ji|.Milc  in  which  pass  the  fibres  from  the  motor  area  of  the  cortex- 
III.-  nsiilt  IS  '-aix.plexy"  or  paralytic  "stroke."  both  terms  implving 
Mijl.lcncss.     A    small    heinorrhaKe    tnay    b».    completeb-    absorbed- 
a  l.iru.T  may  be  absorbed  with  a  resnltiiiK  cicatrix;  there  is.  however' 
'I'l'  tendency  to  the  formation  of  granulation  tissue,  and  thus,  if  not 
l.itiil,  ;i  liir>;c  lieinorrhaKe  is  transformed  into  a  cyst  (see  p  •^*r.i) 

EmboUsm  and  ThrombosU.     Sn,hK.„  apoplectic  attacks  mav  "be  due 
"-a,»r>  otIuT  than  hemorrhage.     Of  these  the  most  importunt  is 
enilM.liM.i.      I  he  arterus  of  the  basal   reKi<.ii  of  the  brain  are  eii.l- 
.■-rt.rio  (sec  p.  :{41),  wherefore  it  follows  that  it  one  of  these  becomes 
Mi.McnIy  p!„K>r,,,|  Uy  ,,„v  |-„r,.ijj„  substance  circulating  in  tiie  WchmI 
tnc.n,.  IS  ,,,t  otf  from  its  nutrition,  and.  as  a  result,  the  nerve  cells 
;".  'M.!  the  ...  rve  fibres  passing  through  that  ares,  undergo  disorL'an- 
i/jitioM.    (  .Tcbral  embolism  may  be  brouKJit  about,  like  emboli.sm  else- 
"l-rc.  I.y  many  aKcnts  (sec  p.  IWA),  but  of  these  by  far  the  commonest 
1^  the  thrombotic  material  constitutinR  the  vegetations  of  acute  eiulo- 
'jiMitH,  which,  broken  off,  may  be  carried  into  the  caroti.ls  and  so  to 
II'  i>nnn.  an.    the  .same  reas.>n  that  le.l  t..  liemorrhaKC  beiiiL'  specially 
nMii.rit  m  the  branches  of  the  mi.l.lle  cerebral-namely  'he  direct 
"MPM.  nt  the  l)l...,,l--applies  also  to  embolism;  it  is  the  arteries  of  the 
"•'-  '■    the  brain  that  are  .si)ecially  ai)t  to  be  involved.     The  result 
"     H.  I,  .iiibohsm  IS  encephalomalacia  ..r  -brain  .softening."  affectine 
'I-  ir..,-,  „t  .hstributi...,  of  the  artery  involvc.l.     There  is  first  .leveloped 
I"  .inn  ol  nccn.sis.  which  soon  uii.l<Tj,'<.es  softeniiiKand  is  of  vellowish 
-H.iiinons  app..aran(r;  most  oft.-n  there  is  no  infiltration  ..f  blood  from 
d"  ofZn     '  ■ '""  'T^*'  'ott^mng),  but  .K.casi.,nally  this  snperv..nes 
,       '°TT,f^'  ^'""'^'  '''"'■*'  *"  '•'■"^'■"  '>•  y^llo^v  softening  as  the  blood 
'^  HHt  ditluses  ..nt  an.l   is  abs.,rbe.l.     The  .liHVrence  between  the 
;    H  ..t  ..mb..i,.,„  aiHl  .,f  hemorrhage  is  that  the  f..nn..r  remains 
^     'tml.N   cir.-umscribe,l    to  the  area  of   bloo.l  supply,  whereas  with 
'  ^npiv,.  .,utp.n.nng  of  bloo.l   the  hemorrhage  involv.s  a  greater 
:";  ■'  ";">'  >^  sni.plied  by  the  ruptiire.l  vessel.     Svmpto.n:,fl,.allv  tluTe- 

■  lannL'Thr.'- ''•?,[""'■"'"'>'  "'""'  "  '^•''""'•'•I'agc  is  apt  to  be  progressive 
'I'inii,,' the  time  following  its  actual  beginning. 


488 


THE  NERVOUS  SYSTEM 


Thrombosis  is  secondary  to  disease  of  the  arterial  wall  or  to  an  embo- 
lus. In  order  of  freciuency  tlie  causes  of  cerel)ral  thrombosis  are  arterio- 
sclerosis, sypliihs.  and  acute  infections  (including  those  cases  which 
follow  embolism).  It  will  be  r.called  that  in  the  subjects  of  arterial 
disease  the  smaller  cerebral  arteries  are  peculiarly  apt  to  show  degener- 
ation in  the  torm  of  atheromatous  plaques  and  of  multiple  miliary 
aneurysms  Such  thrombosis,  originatiiiK  at  one  spot  in  the  diseased 
vessel  wall,  does  not  suddenly,  but  Rradually,  lead  to  obliteration  and 
closure;  there  is,  therefore,  in  general,  an  absence  of  the  true  apoplectic 
or  stroke-like  onset.  The  results  to  the  cerebral  tissue  may  be  identical 
with  those  just  described. 

Aneurysms. ^Aiieur\sms  of  the  extracerebral  and  basal  vessels  of  the 
brain  are  not  uncommon;  they  are  saccular  and  of  the  size  of  a  pea  or 
bean,  and  may  be  the  site  of  rupture.  Of  more  importance  are  the 
multiple  miliary  aneurysms  of  the  intracerebral  vessels  in  advanced 
arteriosclerotic  conditions;  maceration  of  the  brain  reveals  that  these 
may  be  present  literally  by  the  hundn.l,  just  visible  to  the  naked  eve. 
It  is  the  sudden  gning  way  of  one  of  the  larger  of  these  that  is  held 
to  be  tile  most  frequent  cause  of  cerebral  hemorrhage. 

Inflammation.  — Acute  EncephaUtis.— This  is  not  a  very  frequent 
condition,  save  as  caused  by  trauma,  an.l  as  it  occurs  in  the  superficial 
IKirts,  associated  with  meningitis,  and  locally,  as  an  extension  from 
disease  of  the  mi.Mle  ear  and  bones.  Xeycrtheless  certain  of  the  acute 
inteetions  are  associated  with  diffuse  and  generalized  disturbance  of 
tlie  hrain  tissue.  In  rabies,  in  acute  polioeiurphalitis,  to  a  less  marked 
extent  m  influenza,  in  bacteriemia  due  to  staphylococci, etc.,  in  typhoid, 
and  other  acute  mtections,  the  toxic  hyperemia  is  probably  the  cause 
ot  those  symptoms  which  ar.  clinically  grouped  niider  the  term  "menin- 
gismiM.  Saye  the  hyperemia,  tiie  changes  are  microscopic,  and  con- 
sist ot  periya.^cular  exudate  with  infiltration  of  lymphocytes  and  leuko- 
cytes. Ihe  nerve-cell  bodies  exhibit  alteration  of  the  Xissl's  granules. 
in  very  acute  cases,  punctate  hemorrhages  may  be  seen  (hemorrhage 
encephalitis). 

Abscess  of  the  Brain  (Purulent  Encephalitis).— This  mav  be  of  various 
kinds,  cryptogemc,  traumatic,  metastatic,  and  by  extension  from  nearbv 
structures,  especially  the  mastoi.l  region  of  the  skull.  Or  ..sionallv  a 
wcl  -<iehned  abscess  is  found  in  the  cerebrum  or  cerebellun,  associate.! 
with  any  recognizable  focus  of  infection  elsewhere;  doubtless  in  su.li 
the  infection  is  hematogenous.  Traumatic  abscess  develops  usually 
by  the  immediate  carriage  of  pyogenic  organisms  into  the  brain  sub- 
stance from  the  exterior,  although  it  may  happen  that  an  injured  ana 
niay  be  infected  long  after  the  infliction  of  the  injury.  Metastatic 
abscess  is  seen  where  there  is  suppuration  elsewhere,  this  being  a 
hematogenous  (or  lymphogenous)  infection.  Absc^s  arising  bv  exten- 
sion IS  most  commonly  seen  in  the  temj)orosphonjidal  lobe  or  in  the 
cereljellum,  secondary  to  suppurative  mastoiditis;  it  mav  also  occur  by 
extension  from  the  upper  nasal  region  and  frrmi  any  of  the  bone  sinuses, 


THE  BRAIN 

ir  from  the  orbit.     Frequently  the  abscess  in  th 


Clint 


itiuation  of  tlie  adjacent  suppurati 


489 

lese  cases  is  a  direct 


ppens  that  it  is  separated  from  ti 


e  area,  but  it  also  frequenti, 


lis  area  by  a  zone  of  intact,  though 


Mil 

;,  .■;  '.11      •         1    ■       "•'■"  """  ">  »  zone  or  intact,  though 

-'..  '■'!  bra„,  substance:  t..  exph.in  this  it  is  necessarv  to    ■„  sider 

t!'l-;Mb.hty  Ota  metastatic  lymphogenous  infecti.m     ' 

i'  m  abscesses  may  be  n.inute  or  multiple,  as  in  metastatic  cases 
I' ..  ...ore  frequent  ,s  the  large  solitary  abscess,  surroun.led  b  a  In,  erl 
■-••  -lematous  area,  forming  a  roundel  mass;  the  pus  isVl  a  S- 
;t  .Hy  green.sh  and  tlun;  when  at  all  old,  there  is  presen  a  vvd - 
|"i..,l  Innng  membrane,  with  little  or  no  tendencv\o  s  .sequent 
hl.rous  repair;  accordmg  to  its  position  it  mav  rupture  ex  ern"  Iv 
..using  a  purulent  meningitis,  or  internallv  into 'tlie  ve.  tric-kf  *een 
".the  b  Imd"  an-a  of  the  brain,  such  an  abscess  nuu  ^^  n  or  v^S 
without  obvious  disturbance  of  cerebral  function      '  ' 

Syphilis  --Kav,.rite  site  for  spirochetes  as  is  the  brain    it  is  to  be  re 
.nen. hen.,,  that  the  most  striking  signs  an.l  sympton^  o    '^  S.^I 
Mill...     ar..  meningeal  rather  than  cerebral;  the  meningeal  X-s 
-     ><■  -l-lt  with   ater.     More^  than  this,  cerebnd  infec.;"   it    m  com 
I.     I.N  >econdar.x-  to  meningeal  infection.     The  following  are  the  most 
■on.i.on   changes   induce.l    in   the   brain   sub.stance:     (1)  IcepVaU^ 
neonatorum,  winch  i.s  f„un.l  in  newborn,  often  in  stillborn  svpl£s 
>  ^tnking  feature  ,s  a  small-celle,!  perivascular  infiltration;  C  £ 
;;;tl^.n.  o.xcess  of  granule  cells  (Gluge's  corpuscles),  scattered  /Klgh 

I        >lnn  1  be  invohement  of  the  cerebral  arteries  and  arterioles 
■i.ny    hose  on  the  surface  passing  in  from  the  meningfTh^ 

ron.s  which  .seems  to  be  the  eventual  cause  of  those  d  i^nerat  ve 

'l'-i'''l«  ol'lo!^;.:  i'^^'r:  ^''^^^"•^••f  ?turbances,  we  encounter 
'"'  P  '.'<."t  of  localized  solitary  or  mult  j)  e  syphilomas  fnimmft) 
--.vplnhtic  granulomas  may  attain  large  size,  2  c  m.  o"n  ..rfTn.s  ' 

,7; ;■"''."«  >.'7'-..nes-in  short,  may  present  those  svmptoms 

•!-  c^"i;f':;:rr'  ''7f-  ^''-^  '^'^^  °^  the-brL^t 

'I"'  "t  site,  and  the  cerebellum  is  rare  v  involved      In  the 

^t''^<s  they  are  soft  and  jelly-like,  with  a  Vhitish  centr      It 

-J..ne  hrmer  and  may  even  undergo  caseation   ^T  a  wh^ 

Tuhl  '"■?'''  ''^^"•-'•'  **'""  tufHTculous  masses.  ' 

1-         s^riV'^'lf  r  •'•'•'  •^'^■'''"''^-  •^"  -'th  tuberculosis,  there  is  a 
,,  ■    '-  t..,„  tor  the  lesions  to  occur  most  extensivelv  in    -onnectt-^ 

'"  '""'"^'^'^^  ^-^*  P-  ^"•')-      In  the  brain  suKstaiice.  tuberculo  i^ 


9mmmrm- 


f 


4on 


THE  XKianrs  sysTi:}r 


appears  iii  tlic  form  of  coii^Ioinerate  tuherdcs  of  lieinatojienous  origin 
thfso  are  found  especially  in  the  yomif;  in  the  basal  portion  of  the  brain 
in  the  pons,  the  teniporospluMu.i.lal  loI)es,  and  partieularlv  in  the  cere- 
bellnni.     In  the  earlier  stajre  of  f;ro\vth  ti-    caseous  eentre  is  surrounded 
l)y  an  UK  of  small  tubercles  and  sniall-celle.'  infiltration  passing  imper- 
ceptibly mto  the  surrounding  tissue  and  invadinu  it.     \h  the  progressive 
caseation  of  the  centre,  and  extension  of  the  perii)lierv,  large  caseous 
tubercles  are  formed,  as  large  as  or  larger  than  a  hen's  egg.     The  i)rocess 
may  become  arrested,  in  which  case  the  surrounding  fibrosis  is  firm 
and  well  defined,  and  the  mass  may  be  shelled  out.     Occasion  illv  the 
caseous  material  undergoes  sc.ftening,  in  which  case  the  appearance 
IS  much  that  of  a  "cold"  abscess.     It  will  be  understood  that  in  such 
a  case  we  have  a  replacement  (ami  more)  of  brain  substance  bv  new 
tissue  and  the  consequent  increase  of  intracranial  tension  which'  is  so 
l)redominant  a  feature  in  eer-bral  tumor. 

Other  granulomas  such  as  actinomycosis,  glanders,  and  leprosy  are 
uncommon. 

Regressive  Changes.  These  may  be  ditfu>cand  generalized,  or  local 
invo  ving  sharply  defined  areas  of  the  brain  and  their  associated  tracts 
of  fibres. 

General  Atrophy.^ (Jeneral  atrophy  is  best  marked  in  the  progressive 
diminution  in  size  of  the  brain  in  the  old.  Here  the  brain  in  general 
shr'nks,  and  the  si)ace  so  made  is  taken,  both  outside  and  inside  the 
brain,  by  cerebrospinal  fluid:  the  perivascular  lymph  si)aces  in  the  base 
ot  the  brain  are  greatly  widened  so  that  cystic  spaces  appear  in  the 
bram  substance,  and  the  membranes,  especially  the  pia,  indicate  their 
share  in  this  change  by  aj)])earing  (edematous.  The  nerve  cells  of  the 
gray  matter  undergo  a  marked  diminution,  indiviclual  cells  shrinking, 
aiK  losing  their  dendrites,  becoming  more  oval,  and  flnallv  disappearing, 
and  this  not  in  sju'cial  areas,  but  here  aiul  there,  appareiitl'v  at  random. 

Uith  this  diminution  of  the  nerve  cells,  there  is  both  an  apparent 
an(  also,  it  would  seem,  an  actual  increase  in  the  more  lowlv  glial  tissue 
and  fibrils,  so  that  there  results  an  apparent  dilhise  sclerosis  of  the 
diminished  (.rgan.  Associated  with  this  the  convolutions  ai)pear  small 
aiK.  the  gyri  between  them  much  widened. 

Y'ry  simil.:-  appearances  are  met  i)rematurelv  in  cases  of  chronic 
lea(  poisoning  and  in  some  alcoholics.  In  botli  of  these  classes,  the 
gha  and  fibrous  overgrowth  ajijiears  to  be  even  more  pronounced  than 
in  the  senile  brain.  To  another  markedly  atrophic  condition  we  have 
already  referred  that  seen  in  dementia  paralytica.  Here  it  is  that 
arterial  changes  of  syphilitic  origin,  affecting  the  arterioles,  character- 
ized more  particularly  by  a  perivascular  plasina-celle<l  infiltration,  are 
ol)viously  the  primary  cause  of  the  degeneration.  With  the  conseriuent 
malnutrition,  there  is  even  more  extreme  degenerati:)n  of  the  eorti(al 
nerve-cell  bodies  (and  of  the  neurones  in  their  whole  length)  than  ocdirs 
in  sende  atrophy.  Over  !).">  per  cent,  of  cases  of  dementia  paralytica 
give  a  positive  Wassermanii  reaction,     Thi'*  disease,  therefore,  '\uw<t 


'---'    I    -lOMIt 


THE  liKMX 


401 


Uvv^mM  as  a.i  atn.phy  c.f  the  brain  secMi.lary  to  chronic  syphilitic 

Local  Atrophy.     This  n.ay  In-  brought  about  by  manv  causes,  chief 
.mn„,  wuch  are  circulatory  .listurbances,  ,,rcssure  of  tumors  or  o 
nv..r,nnvth  ot  the  u.ner  tab  c  of  the  skull,  prcssur,.  of  l,.calize,l  inflam- 
n  ,  „ry  processes  an.i  the  cl.sturbe.l  nutrition  set  up  bv  the  same      I„ 
-Miti...  wc  n.ust  recoKuize  abiotro,,hic  phenomena  clue  to  inherited  or 
^p>nu->\  premature  exhausfon  of  the  neurones  of  particular  areas  of 
.  -■  bnun.  as  also  the  .hsuse  atrophy  which  n.ay  follow  the  cuttiuR-off 
o    Mcurunes  from  the.r  d.sta    ,,ortious,  either  peripheral  end-or^aifs  or 
.•.r!,nr,  ,mo„s  aro.m.l  the  cell  bo.lies  of  other  neurones.       It  is  these 
IMPfal  atrophies  that  are  so  characteristically  accon.panied  bv  <lejrener! 
a  .nn  ot  partu.ular  tracts    whether  asculing  or  descen.linf,",  and  it    s 
..■     a      aye  ,.ven  us  the  knowledKc  we  possess  of  the  finS  anatcuuv 
t  u;    ram  and  cord.     1  he  processes  that  occur  in  this  ,,artial  atrophv 
:ir.  .,t  the  sanu- order  as  those  seen  in  the  general  atrophv  just  described 
Progressive  Changes.     The  struc-ture  of  the  brain  differs  fro      a  i 
;     J'  ..r.ans  ol  the  body  m  that  both  its  spcciftc  elen.ents,  the  neun.ne 
1  n.  >pec,hc  connec-tue  tissue,  .he  ueuro.dia.  are  of  epiblasti,-  origin 
lU'    mooiast.c  elements  m  .t  ar..  comparativelv  sight,  consisting 
-n<;n  .y  ot    he  ^•essels  and  the  small  an.ount  of  connective  ts"uec™- 
■  "Ht,n,  the.r  ad^ent,tia.     It  follows  thus  that  progressive  changes 
'  ;— ly   u,  conuectu.n  with     ''  epiblastic  elements.     Progressive 
la  ue.  m  connection  with  the     .    ,els  are  comparativelv  rare;  These 
^^'  M.;,y  f,rst  d,s,.n.s,  u,  stating  ti,..t  angiomas  have  been  rec,  r  |e    in 
-;-m^w.h  the  cortex,  and  then  of  pial  rather  than  ^'IS^^^ 

"      .l!    r  r  ""•'  '"y^r*'  Yr  '•'"•  '"'*-'"  '•^^^■"'••'-''  tlH-  former 
r  T   ,h,   latter  s.nall  and  roun.h.l.     So,  again,  there  are  verv  rare 

-  -'t   .rc-bral  osteoma      More  frequently  are  encotmtered  n.etaplaTtic 

-  .  M'lacpus  of  the  bram  n.embranes;  these  cannot  be  rcgard^l  as 
'  H.  s.     sarcomas  onginating  within  the  brain  substanc-e  are 

'innlv   rare  ■;  we  except  the  most  anaplastic  form  of  glioma    the 

'„,''"'''  ?".  ''^'  ""'>■  "*  connective-tissue  origin.      AVe  shall 
n,:  ,;,l.;;nl;:  ^"^°*^«^«™-  -•'-  *'---ing  the  tumoi  of  the  1.^11 

Glioma.     Here  we  „u,st  in  the  first  place  distinguish  between  this 

'  ■'i:;Hv'd;:i;,'f^r"  ^'^r'^r  -  -'-•>•  -  encou.;*:;!:':;? 

"-n,i     1    .1,  ,1      •  "T      I      '"'  ^"V"""'"""^*'  overgrowth  of  the 

piMl  tUmn   s.     In  such  a  case  the  tumor  passes  impercentiblv 

•'■  t  ,,.  surroun.hng  tissue,  and,  what  is  more,  if  t  alfect  a  con"ol  ted 

;;;;-;  .onvolutjous  are  stdl  maintained,  although  thei'a;:XS 

'--M   in       .;  '    ':  Vl""'  ''  ''""^'*';'"«  ^1^>'>'"»  ■'^  '"cre  hyperplasia, 

.  "      ™e  ghoma  is  usually  solitary,  tends  to  be  spherical,  and  by 

'.     "I'T  and  consistence  is  rerotrniyabiv  di-jfinr-t  fr^i,,  tl.  «""".> 

>    -i'.     in  c.lor  tl„.  „r  ;.-•"'-" '".^  ''7"^"  trom  the  surrounding 

«'>l"r  the  glioma  is  grayish  pink,  somewhat  more  trans- 


~  '!eif 'offsif  ««r,'«»»  ~riir  ii[~M-mi 


402 


THE  \ERVnCS  SYSTK.V 


I.Kvnt  than  the  I.rain  sul.sta.u.o.  a.ui  ,„ay  I,,-  ntlu-r  rdativelv  poor  in 
the  .hoi.  of  the  ttunor"      ,.  ,   •wln^L^^Z' ^"  ""^^ ^'r^''"' 

l^l^t  V  ""'  "'■""''  ■■>■""■  «iv  ti,»  lined  l)v  o  cubloal 

irom  tlic  tourtli  \  eiitrick-  have  l)een  reported.     Apparenth-  these  enen 

;!=^;:- ;.:t;:"^'"  '■'-'^■'  ^-^^  -  -^  ^pitheiiLnatc!^  ;:r  :;s;;: 

hypernephroma  and  chorioepithelioma  are  ooc.asiomd  v     3  't  e    ^ 

Cvt  ''"'("';"";•  '•"•'''^'^*'-:  »■-  this  site  than  th^  two  fomer 
''riidcvsts;  o^«nLH'"'''r  "''''"■^-  '";'-^'  '""  "'^'"»ntere,i  in  the  hrain; 

cy   s  rn;|.^r.T'!'''  rV*-  """'"'"•■•^'  ^"  '"■•^'^'  l.enu.rrhages;  necrotic 

'h  ,n..!'  ;  re  7  ^I'ttv-ng.  appearing  also  i„  conneetion  with 

pa  aSic    r     r'  ;""^'^^:;"^'"''''.'J  porencephaly  (p.  48(i),  an.i  h.,sth- 

coccTs     S  Vr         ""'•  "^'V'"'^  '^-'^''  "*'  cy'^ticercus  an,!  echino- 

Xe  of  :?  r       '       TP'  ^••''."•.""•^''^"^  f>y(lati.ls  are  large,  even  to  the 
tumor  '"'  "'  '"  ""'"■  ''"'■  ^''''  ^^^  *''^-  symptoms  of  a  brain 

THE   PITUITARY  BODY   (HYPOPHYSIS   C  REBRI) 

fnVC  i''^*"'"r>'  '""'y  •''■^"^••^  separate  mention,  in  that,  while  attached 
oonmM  l"";  ir  """"  ^•V"^t't'»'"t  i^  "ot  nervous  tissue;  it  is,  indeed, 
composed  of  three  portions:  the  anterior  glandular,  an  inttnncdi.te 


77/ A'  SI'lXAL  CO  If  I) 


493 


una  witli  Klarid  colls  iiitoniiixod  with  muiroglial  tissue, and  the  posterior 
juiKli.mid  portion,  also  of  jjlial  tissue  without  nerve  fibres  proper. 
i.ittif  is  known  reRardinn  its  function  save  that  the  posterior  an.l  inter- 
iiitdiatc  i)ortions  afford  an  extract  wliich,  like  adrenin,  greatly  raises 
the  hlood  pressure,  and  unlike  adrenin,  induces  polyuria  by  acting  di- 
nrtiy  on  the  kidney.  The  main  pathological  interest  of  the  pituilarv 
\\v<  in  the  relationship  between  hyperplasia  and  adenomatous  growth's 
nf  the  anterior  portion  and  the  development  of  acromegaly  (see  p.  101). 
Chantri-.  have  also  been  seen  in  the  jMtuitary  in  connection  with  preg- 
iiancN  and  castration,  as  again,  secondary  to  removal  of  the  thvroid 
sliind. 


THE  PINEAL  GLAND  (EPIPHYSIS  CEREBRI) 

Aiiatoniieally  the  pineal  gland  represents  a  rudiment  of  the  median 
eve  still  recognizable  in  certain  lizards;  it  consists  thus  of  ptirelv  nervous 
« liincnts;  at  most,  it  may  be  the  seat  of  hypertrophy  and  gjiomatous 
timmrs,  which  by  their  size  may  press  ui)on  the  aqueduct  of  .Svlvius 
and  the  vena  magna  (ialeni  and  so  bring  about  hydrocephalus  internus. 


THE  SPINAL  CORD 

AnomaUes.  Here  may  be  recalled  some  of  the  more  important 
"m-nutal  abnormalities  of  the  spinal  cord;  they  are  relatively  infre- 
qurnt  an.l  do  not  call  for  extensive  description,  ■jncomplete  formation 
aiii  >h.irtening  of  the  cord  is  observed  in  cases  of  anencephaly  combined 
"itli  -pnia  bifida  as  also  in  simple  spina  bifida,  to  which  reference  will 
I"  "iide  later,  duplication  of  the  cord  has  been  observed  both  in 
'^iiM>  (it  partial  double  monsters  and  apart  from  anv  clear  evidence  of 
'.hi|>  i.ation  of  the  body  in  general.  ])ui)lication  of  the  spinal  canal 
1^  alH,  r.,„rde(l;  this  may  be  partial  or  complete,  when  it  appears  to 
"■  til..  \,Ty  slightest  case  of  somatic  duplication.  More  important, 
'"'•inM'  more  ommon  and  more  obvious,  are  the  various  grades  of 
spina  bifida  (rachischisis).  Here,  anatomically,  we  deal  with  the  various 
"'i"'i'i"iis  ot  incomplete  formation  of  the  laminae  of  the  vertebrre  but 
"■"•'flying  tins,  in  the  extreme  cases  is  a  lack  of  closure  of  the  dorsal 
■;''"'•,  whereby  the  two  halves  of  the  posterior  portions  of  the  cord 
■''I  '"  nnite  and  the  ependyma  of  what  ought  to  be  the  spinal  canal 
"ii"'-  vMth  the  true  skin. 

W.  iia\c  >.'->ady  referred  to  the  various  forms  of  this  condition  in 

'•-"i-mg  t..,   abnormalities  (see  p.  72).      Here  we  repeat  that  the 

';•  '  ifKMi  may  affect  the  whole  length  of  the  cord,  or  mav  be  partial 

■    '  "I'll;  a  portion  thereof,  and  may  be  complete  or  incomplete.    Thus] 

the  eystic  form  of  spina  bifida,  we  may  have  a  series  of  cases  in 

""  "i^rely  the  laminae  are  defective,  the  cord  being  perfect,  the 


n.-,  I. 


494 


rilF.   SKliViHS  SYSTEM 


sliKlit.-st  orm  bcu.j;  tlu- spina  bifida  occulta  in  which  fattv  tissue,  in  „ai 

ttv:;''7n""  r^"*"'^'?"  Y'*''  ''''■  ^•"■'"'  ""•■"■"»^'^'^'  '"I'Hrt  filling  th 
cl.h-ct  ot  the  Ix.ny  an.l  suhcutan.-,,,,.  tissues,  fur.ns  a  projeetinR  n,as> 
wuci.,  .unuusiy  .s  ....vere.l  hy  a  skin  that  is  extra.lnlinarilv  hain 
J  h  s  torn.  ,s  ,nnst  fre(,..ently  Men  in  the  hnnh.,saeral  region  and'appear 
to  l,e  cosely  related  to  those  cases  of  fatty  pn-j.-etions  c-overed  hv  hair^ 
sk  n  w  uch  consftute  "talse  tails."  Fro„,  these  slightest  c-ases  we  pas' 
t hrouKli  a  series  ot  eon.hti..ns  of  meningocele,  in  which  the  defect  ii 
iu-  bony  vault  .s  oee„p>ed  by  a  sonu-what  cystic  expansion  of  the  men. 
n>ges  hlled  wth  fluid,  and  in  which  the  spinal  ccrd   s  not  involved™, 


"nourT.ra        "    ;     "    '     >    "f''^'""^'   "'^   "^■'""-^  «™ove  remain,  or«n;   ^p..,  epuicr,,,; 
•1,  utur.n  trait,  pa.s.,  i)ia-ara<linoi(l  apacf.  ■      .      .•   .     i 

to  casc-s  c.f  myelocystocele  in  which,  while-  the-  spinal  canal  is  complete, 
the  lack  ot  sup,,ort  n,  the  r.-j;ion  where  the  lamina-  are  defective,  results 
n  a  ocah/ed  expansion  of  the  s,,inal  canal,  to  c-ases  in  which  the  .spinal 
(dna  has  faded  to  for.n  and  while  the  anterior  dura  and  pia  are  fullv 
.leveloped,  the  spn.al  cord  is  represented  by  an  imperfect  and  intenselV 
f'<jnKc-stc>cl  layer  o  nerve  tissue  c-overed  posteriorlv  and  superficiallv 
by  a  layer  ot  epen.lyma.  In  these  cases  occasionallv  owing  to  th"  want 
of  support,  Hmd  may  accumulate  in  the  anterior  part  of  the  pia-arach- 
noid  space-,  tormmg  thus  a  tumor  projecting  backward,  the  myelo- 
menmgocele.  '     v         o  ,  * 


TIIK  SriXAf.  COIil) 


495 


(V..s,„,.ally    wholly  unass..c,ato<l  with  any  .IdVct  of  the  lamina 

-n'  may  he    c.cahze.l  myeloceles  or  .iilatations  of  ti.e  neural  ca,^ 

.II..1  u.th  oereWpn,al  flunl  (hydromyeUa).     This  eon.lition  mav  be 

compare.!  w.th  hydrocephalas  intemus.     As  t.,  the  causes  of  the  eon.lition 

«c  know  httle,  save  that  n,  some  cases  it  appears  to  he  conRen   a 

[.  :'^^  ";:'""-•'■     '\  ^--ter  elini,.l  interesl  is  the  somewhat    Ire 

|"n.l,t,on  ot  synngomyeha,  .n  which  aIon«  the  ..ourse  of  tlu-  conl  is  to 
1-  tonn.l  one  or  more  .rre-m  ar  .lilatations  of  the  central  -.nal.  which 
-  Mna!  m  the  normal  nml  as  to  he  practically  invisible,  mav  be  so 
M.n.Ied  as  to  a, Im.t  a  finder.     In  general  ti^ese  cavities  ^re  irregular 
>  a  .e;  m  general  also.tlu.y  are  surroun.lcl  by  a  layer  of  hvperplastic 
a     ,ssue.      I  he  .hlatat.on  an.l  cavity,  being  ..entrally  loeate.l.^afTect 
t  .•  fibres  passn.g  over  m  the  commissure  and  prod.ice  .lissociated  loss 
;    -MS. M.ty  to  pan.,  h..it,  and  cold.     It  is  still  uncertain  how  far   h 
,M>  ,.  t"  '-  regarded  as  o    pri.nary.  how  far  of  secondary  origin 
..t  ..  part.cularly  noticeable  is  the  in.lication  that  this  condition 
.n|>  ot  the  existence  of  tactile  as  <listinct  from  other  sensorv  nerve 
i  a  cnnsulerable  proportion  of  cases,  tactile  sensati..n   is  VetaMied 
H.n|.s  t  e  senses  o   heat,  col.l.  and  pain  are  lost.     It  is  hel.l  bv  '  me 
t      atrophy  and  necrosis  of  areas  of  the  gliomatous  new  formation 
l.nnr  tie  ..ccnrrence  ot  these  cystio  (lilatations. 

r,    S'T  °"f,»'»°«=f.«--;n.ere   is   little  that    needs   to   be   said 
in''  •IP;"'"'"'--^'  "'f  nrbances  of  the  cord  as  .listinc-t  from  those 

li     I,         ;  t        .?■  '""•'  ^:  *°*™*  ""•'  "**^«  »"•'  passive  congestioii 
1^1     about  by  the  same  factors  as  in  the  brain.     At  most  mav  be 

;  M    Mrallel  «,th  the  still-extant  central  canal,  which,  aeconling  to  Van 

:  H;:  •:  ^^"""T  ""'•'""--''"«-  -«*";  tl-  are.  in  f^t  poSl 

,  i  f  'r-;-.    H«'°>0"haKe  may  occur  in  purpura  and  the  blood 

■  -.though  It  IS  usually  a  result  of  trauma.     It  has  been  suggeste 

'     u,;^.;;';;  ;;l^;;  •;  "-''->•  «I--"  arc  not  purely  fuiictional,Kl^ 

^^,  ;^;;lt  ..t  .n,„It,,h_  J^^^  ,„to  the  substance  of  the  cord  with 

Inflammation.     Inflammation  of  the  cord  is  known  bv  the  eener-.l 
'•       '•  r,.as.     It  may  again  be  divided  into  the  form  which 

PoUomyelUis.'  '''  "'  *''"*   •''^^'^^'"^  ""»"'^-  '^^   ^^-V  -atter, 

in       I'bte"  ;-"' ^"-^  l"^  *•-*  P-^"-!  ^y  -npression. 


til 

;ttl' 


.■IF, 


■I- 


'  >nirr;.n  !/^':ia!^!: ^«;"  -"""^"-^  -«  ^-te  distinct. 


•M-rliti 

(ir  l.i.th,   a 
t'li'i:.'!   ill 


i>r.,.,orl,-o     ■  II    I  •     .         "'" '^""""^""is  are  quite  distinct, 
ro  erl    so-called,  is  the  result  of  infection,  or  acute  trauma, 
s  characterized   by  .lefinite  reactive  processes.     It  i 
..cute  general  intect.ons  and   i„  certain  specific  infection 


gray;  //i;/.ir,  marrow. 


I'M) 


rut:  sERvois  system 


afFecting  ospfciiilly  tl.o  cor.l,  i)rtrinitient  nmoiiR  which  is  that  knov 
as  acute  i)()h()inyciitis.  Wtv  important  ah  .  are  those  forms  in  whi( 
infection  occurs  by  extensi(.n.  as  in  .liscase  of  tl:o  meninges,  notab 
cerebrospinal  meningitis,  or  of  the  vcrtebrie.  as  in  caries.  In  all  cas- 
of  true  acute  myelitis  the  aH'ecte<i  portion  „f  the  cord  appears  pin 
more  hyperemic  than  normal,  soft,  so  that  it  is  almost  impossible  1 
cut  It  cleanly,  and  somewhat  swollen.  .Alicroscopicallv,  the  mai 
fniture  is  a  small-celled  infiltration  around  the  vessels,  with  evident 
of  degeneration,  whether  in  the  Kanglia  cells  or  the  mediillated  fibn 
constituting  the  white  matter.  With  this  there  mav  be  an  increase 
number  of  •'granule  cells"  scattered  through  the  atlected  area  Th 
ultimat"  results  are  atrophy  of  the  specific  elements  iMid  a  moderat 
degree  of  glial  proliferation  (sclerosis)  with  accomiianving  diminutio 
in  volume. 

Regressive  Changes.- Just  as  in  the  brain,  so  in  the  cord,  with  ol. 
age  there  is  evidence  of  simple  atrophy  shown  bv  diminished  size,  som 
shrinkage  and  pigmentation  of  the  nerve  cells  of  the  grav  matter,  and 
in  addition,  more  particularly  in  the  white  matter,  is  to"  be  recognizee 
an  increa.sing  number  of  corpora  amylacea,  small  corpuscles  varvinj 
trom  1-  to  50m  m  diameter,  staining  deeply  with  hematoxvlin  and  th( 
ordinary  aniline  dyes.  These  are  specially  numerous  in  the  postcrioi 
columns.  V^  hether  they  originate  from  glial  cells  or  from  degenerate. 
meduUated  fibres  is  still  a  matter  of  uncertainty. 

As  already  stated,  acute  degenerative  changes  result  from  trauma, 
traumatic  compression,  hemonhage,  and  infection;  more  graduallv  pro- 
duced degenerations  may  result  from  tumors,  gummas,  and  tubercu- 
lomas, either  ii-  the  cord  itself  or  in  the  brain.  It  is  more  usual,  however, 
to  encounter  the  later  stages  of  the  degenerative  process— secondarv 
'legenerations  manifesting  themselves  by  atrophv  and  sclerosis  of  one 
or  more  of  the  ascending  and  descending  tracts  in  the  white  matter, 
and  by  shrinkage  and,  it  may  be,  absence  of  cells  and  cell  groups  in 
the  gray  matter.  Here  the  accompanying  figure  will  recall  the  more 
important  oi  the  tracts,  divided  into  the  ascending  and  the  descending, 
the  hmg  and  the  short. 

We  need  merely  recall  that  no  matter  what  the  nature  of  the  cause, 
these  secondary  degenerations  are  all  of  the  same  order. 

\\e  are  made  aware  of  degeneration  of  this  secondary  nature  bv  stti.h 
of  serial  .sections  of  the  cord.  During  the  development  of  the  degen- 
eration various  special  methods  of  staining,  notable  among  which  are 
.Marchi  s  and  Weigert's,  i)ick  out  for  us  the  affected  fibres,  largely-  in 
consecpience  of  the  chemical  substances  resulting  from  dissociation 
of  the  myelin  of  the  medullated  sheaths.  Later,  when  the  process  of 
disintegration  is  complete,  and  the  fatty  matter  has  been  absorbed, 
ordinary  histological  stains  demonstrate,  by  their  failure  to  color  the 
tissue,  that  the  axones  and  their  sheaths  have  largely  disappeared  and 
have  been  re!)|jiced  by  firmer,  more  translucent  fibroid  tissue,  the  out- 
come of  glial  i)roliferation  (sclerosis).    These  areas  of  degeneration 


'if': 


'M 


d  \i 


THE  SPIXAL  CORD 


497 


en--,  .l..,nu.rati„„  in  tlu- 1  J  it        ti       L'L';';  T  1     "''  "7  "^ 
- '■•"•ily  "HVcte,]  by  that  W.genen.t'icn,  "'"''  "^  "''"^'" 


Fia.  237 


ni.uM 


Via.  23S 


or  and  (lesconding) ;  5, 


Tuh, 


A 

thr 

h.'ilH 

(•nrt( 

.'tirr 
I'llli; 
ViiM  • 
in;.-, 
A 


,  '  >."„|,k  of  ,l,e»  «.c„„dar.v  degenerations,  let  u,  suppose  that 


49S 


77/ A'  XKHvors  sysTim 


the  .■..r.l  Ims  l„ri.  iK.nnsct.d.  that  is.  o.u-lmlf<.f  it  l.as  I „  ,.„t  tliroi,«lr 

tl.f  kiiil,-  l.as  s,-v.T.-.l  vun  tra.t  an.l  ..very  longitudinally  disposwl  fjlw 
in  tl.a  halt  ..f  tJK.-car.l.  I'lu-  .lesciHlinK  fihn-s  that  l.aNe  been  ,ut 
show  .leKem-ratu.,.  /./,,„.  tl»-  section,  that  is.  special  staining  methods 
will  nt  hrst  show  thes,.  hhres  n.  their  staf  of  .le^eniration.  and  later 
their  disappearance  and  ivplaeen.ent  l.y  s,|,.rosis.  Theaseendini;fil,res 
on  the  other  hand,  are  relatively  iinaHVeted  l.el..w  the  point  of  inj„rv' 
It  IS  above  this  that  the  degenerations  arc  >een. 

Based  upon  these  ;;,.neral  consid.rations  we  ina\  cla.-ifv  tiie  main 
diseases  afhrtinK  the  cord  ac.or.lin>;  to  whether  ii.e  lesio"ns  are  .lue 
to  (1)  .lestniction  ..I  the  iipp.r  in..f..r  ncnn.n.s;  r2)  injuri.-s  affectlnE 
the  axones  ..f  those  upp,.r  motor  ncnr.mcs  .Inrin^  their  eoirse  down  the 
cor.  ;  (A)  mjuries  of  the  L.wer  motor  nenroi.es  (.liseases  of  the  axones 
of  these,  the  periph.Tal  nerves,  will  be  c..nsi,|,Tc.l  separatelv),  an.l  ( }) 
.liseases  or  injuries  allVctitiK  the  sens..r>  neurones  fr..in  th"e  post.rior 
KauKhon  upwar.l,  an.l  (.-,)  .liseases  allVctinR  motor  an.l  sensorv  neurones 
comeideiitly. 

It  seems  i.e.essary  in  a  w..rk  of  tliis  sco|,e  to  leave  ..nt  the  i;r.-at 
mass  ot  chnica  detail  that  is  inv.,l\,..l  in  any  full  .lis,-ussi..n  .,f  th.s,. 
various  spinal  .lis..nlcrs;  we  .an  m.r.ly  in.licate  the  .Uderent  tvpes  with 
oiitstandiiifT  examples.  '  ' 

1.  Diseasfs  Affrcfim,  thr  Cranial  Distribution  of  the  Upper  Motor  Ne,- 
r«»<..-Congemtal  spastic  paraplegia  is  a  well-marke.1  on.lition  in  wl.i.h 
nerye-cell  b...lies  in  the  c.T.-bral  c.rtex  luue  been  .lestroved.  usuall\- 
by  trauma  at  birth  or  ayain  by  obliteration  of  ,er.-bral  vessels  .lurin'j: 
f.rtal  lite,  as  m  congenital  porencephaly.  Similar  spastic  paralvsis  of 
like  origin,  nain.ly.  thr.,uph  .hstrn,ti..n  of  c.rtical  nerve  cells,  mav  he 
of  postnatal  origin,  .Im-,  f..r  .xample,  to  the  presence  of  tumors,  infective 
granulomas  .)r  vascular  ..bliteration  (acquired  porencephaly).  As  regards 
the  cerebellar  n.-ur.,n.-s,  the  i.leas  <.f  many  authorities  compel  lis  to 
include  here  Friedreich's  ataxia  as  owing  its  in..st  imp.)rtant  svmpton.s 
to  an  atrophy  ot  nerve-cell  bo.lies  in  the  cerebellum.  In  'this' rare 
familial  .l.scase  it  must  be  remembere.l  that  there  is  also  a  spinal  lesion 
ot  botli  m.)t.)r  and  sensory  systems. 

Perliaps  the  commonest  of  lesions  in  the  cord,  secondary  to  priniarx 
insults  111  the  l,rain,  are  those  following  upon  cerebral  hemorrhage  aiul 
cerebral  thrombosis.  IIem.,rrhage  affects  most  frequently  the  internal 
capsule  an.l  the  p..ns,  d.'stroying  axones  of  onlv  one  side  of  the  bo.lv. 
In  multiple  sclerosis  with  its  sporadic,  irregular  distribution  of  scleros.",] 
areas  ot  primary  degenerati..n,  .Mthcr  the  cortex  or  the  cranial  tni.  t. 
may  chance  to  be  inv.)!ve.l.  an.l  so  l.-ad  to  secondary  .legeneration  in  tli.^ 
motor  tracts  of  the  cord. 

2.  Disease  Affecting  thr  Jj-ones  of  thr  Upper  Motor  Neurone  dnriwi 
I  heir  Course  hwn  the  Cord.- The  broa.l  effects  of  such  diseases  m- 
identical  with  those  ..f  the  previous  category;  we  make  the  separation 
bccau>je  here  tlu-  disease  acts  within  the  cord.  Strictly  speaking,  we 
must  here  mcludc  conditions  of  myelitis  difluse  or  localized,  because 


1 , 


.^'^m^^m' 


THE  SI-ISM  I  (nth 


499 


* :  .*:vi;:;i;;r:,:r:i;;!:t;^:;.:'  it^rr  '>-"  •"-  '■"-" 

^MiMii.trical  sclerosis  „f  l,.,t     <  r  ,"   ^'''•''•"^'^  '^  "  I)riinary 

'liM>  >tri.tlv  n.id.t  l.av,.  l.rr     i,        I    I       ..  "'.'*'""  '"■'"•"'•i'.  '""l 

:''- "'•1 i'.--'."'v„:j;;;::,:i  ,:'•"' v;,:;:^^^^^^^^ 

i— <<  II  111  tic  family  tvDi»  nf  i«f„.i      1       •         /'"^  ""tcra  I  .sclerosis 
sclerosis   uvl.c^cX^!rr     n  t  r    .nmr,"''    '""T""'?''  ^*"*» 

tumors. Mi  tlicinfecLirruiomls    ^'""'"  '''—'"":  -  «'-  with 

'"'•>  riu,  in  cranial  lur  c     .         !    1    !    V  ."*  *''.'"  '"•"""^  "*'  ^'"■'^«'  ^•^'"-^ 
""  .^n-  here  .1  /  vit      ii  f. "■*  •"'';  '"■''"■'"'^'  ^•'■•'t-  «'tl...,iKh 

i'~  .-.x-M,,..    Ti.c  i,n  Jrcssiv  .  •  tr         •  '"  ''"'*"''  '"•'*'"■  "^'•"•'"»-  ""<! 

^^'-'".;:s;;;.;;'";^v:tsrt;;:'' "  h'^'';^ ''  ^''^;  ^■'•"••"^  «-*^  '^•"-. 

'"'I  '"ii-  .rnc.  ■  ■ '  w  .    .        '"'^'-r" '"""l^'-^  "t  tl.o  Kray  matter  at  tlie 
'u-ors,  ,„„, ';;:!  .L;!!';  '"  '-''"•"^  "^  ^vrn,Ko„,veiia.  multiple  sclerosis! 

-''^"'^'^^^^^  ^''r  ""^--  horns  an<i 

A^n,-I)i,clu.nne)      In    hiU        .    .  P'«f"««»^«  ""scalar  atrophy 

■-S  tn  l,c  t^  ;  ;,  r  ;•    Pf  •^"•^■^?'^-^'  over  years,  and  appears  i„ 
'  <•  P  •'<  0      f^,    /    *  '\^"xem.a  act.ng  in  tlie  sul.j.r     .f  al.io- 

votropL"  later  *"  !''"•  "'"lar  groups  of  lower  inotJ.r  „. 

n-'ur'nc-  tl  fs  ,  scleroses  il.ere  is  also  .legeneration  of  tl, 
'"■..n,  ,  tins  iias  already  been  coiisidered. 


«<i  til 
inft 
iiirl 
|':ir;ilysi 
It  i-  «( 
i-  iii.t  I- 


till  ii 

fl,n. 

tr,,;. 
In  . 
llii!;, 


)IO- 

iroiics.. 
the  lower 


.KM) 


77/ a;  SHHVOI  X  SYSTHM 


I.  Dhrnnrti  Affntimj  I'rimiiriljf  tlir  Sin.iiiri/  .\riiri>iiiK.  Ihrr,  first  and 
fomiiDst.  In  to  l)(-  n'('<i^'ni/(-<l  tab«s  dorsalis  or  locomotor  atutia.  Tlu 
cliiiractcristic  U'sicm  is  mi  as<fiiiiiiin  il<p'iHTatii)ii  atrrctiiij;  tlic  |)<»ttriiii 
<'(tliiiniis;  ill  short,  this  is  a  srnsorv  iM-iiroin'  disrasr;  as  to  th»'  caiisf  o| 
it,  th«'  Wassfrinarm  n-action  lias  proviil  coiuliisivrly  tiiat  marly  al 
rases  an-  of  syphilitic  origin. 

Kfnaniinn  tin-  rxatt  iiatiirr  of  tin-  i)ro<tss  hriiiniiiK'  ahout  tlu-  (l<'j,'tn- 
t-ratioii,  opiiiioiis  art-  still  iliviilol.  Coiisidi-ralth'  attention  has  iK-eri 
pai<l  of  late  years  to  the  (le){eiierative  chanjjes  seen  in  the  posterioi 
root  pin>tlii«.  hilt  it  is  now  >;eni-rally  ae<'epte(l  that  th<  m-  are  not  sufficient 
to  explain  the  extensive  (ieneiieration  found  in  tin  posti-rior  eoliiiiins 
So,  also,  certain  observers  have  called  attention  to  locali/«'d  nieniiiniti> 
with  thickeiiin>;  involviii),'  the  nieiiin^'es  of  the  jiosterior  as|M(t  ol 
the  cord,  and  have  assumed  that  the  contraction  of  the  filiroiis  tissia 
around  the  enteriiif;  |)osterior  root  fibres  is  sufficient  to  cause  an  as<eiid- 
luii  atrophy  and  sclerosis.  We  are  inclined  to  ai'cept  the  view  ol 
Mott  that  the  syphilitic  virus  atlectinjr  the  vitality  of  tin  ^ensory 
neurones  may  cause  a  de>;ciieration  that  first  shows  itself  pt  iii)lierally 
and  only  with  its  projjressive  ad\,ince  l<riii>;s  about  a  final  atrophy  ol 
the  nerve-(  ell  body.  It  mijrlit  be  su^rKcstt-d  that  we  deal  w  itli  a  sdeetivt 
action  of  the  syphilitic  virus  telling  |mrti<ulnrly  upon  the  sensory 
neurones;  there  are,  however,  indications  that  this  view  is  incorrect 
that  syphilis  induces  a  >;eneral  lowered  vitality  of  all  the  neurones 
thus  in  those  showing'  the  early  stages  of  tabes  and  accustomed  ti 
jiarticular  recurn-nt  muscular  movements  (])olishers  an<l  the  like)  a 
fre((ueiit  symi)tom  of  the  disea  is  |)arcsis  and  wasting;  of  the  miiscit- 
involved  in  these  inovcincnts.  The  reason  why  in  the  cord  the  sensorv 
system  is  particularly  involved  a|)pears  to  be  that  in  the  rnaintenaiui 
of  muscular  tone,  etc.,  these  neurones  are  in  a  state  of  eontiniioii- 
activity,  whereas  the  anterior  motor  neurones,  acted  upon  as  tliey  art 
from  two  sources,  viz.,  from  the  brain  and  from  the  cord  (ui  reflex 
action)  have  a  period  of  comparative  rest  durin>;  sleej)  when  the  cerebral 
stimuli  largely  cease  to  act.  If  the  vitality  of  both  orders  of  cells  he 
depressed,  the  sensory  neurones  are  more  liable  to  become  exluuisttil 
than  are  the  motor. 

Apain.  as  in  all  the  fore>;oiiij;  groups,  multiple  sclerosis,  myelitis, 
tumors,  gummas  and  tuberculomas,  acting  on  some  portion  of  the  posttrinr 
columns,  may  lead  to  a  secondary  ascending  degeneration. 

').  Diseases  of  the  Spiiinl  Cord  Affecting  Motor  and  Sensory  Fihn.s. 
Here  we  have  to  take  into  account  all  those  disturbances  of  the  spiiiiil 
cord  which  result  in  <lestriiction  with  subsequent  sclerosis  of  iM'tli 
ascending  ami  descending  tracts.  Such  are  all  those  that  affect  the 
whole  cord  or  all  the  substance  of  half  the  cord,  such  as  the  form  alM.vc 
mentioned  of  myelitis;  such,  also,  may  be  any  of  the  lesions,  iiior.'  <ir 
less  accidentally  ])|j.(ed,  such  as  tumors  or  the  granulomas.  It  must 
be  remembered  also  tliiit  in  diseases  which  we  commonly  regard  as 
di.seases  of  one  system,  a  certain  proportion  of  cases  may  slio^^  an 


Tin:  Mh:\i\(.i:s,  cr.wim.  wn  si'I\.\l 


rA)\ 


iiii|tli(iitiitii  i»f  II  si'coiul  systfin;  thus  in  talu's  <l«irsalis,  wlu-ii  the  l)raiii 
i>  iiiM.Kiil  fciviiiu  ris«'  tu  >r«in  nil  parrsis,  tlirn-  riia.v  he  a  sclerosis  (»f  the 
hiti  rill  (iiiotiir)  tract  as  well.  Wlwrc,  as  in  multiple  iclerosis,  luitnvrous 
jirri-  111'  [iriniarv,  localized  ijcstniction  of  tin-  spinal  tissue  have  their 
iiiL'iii,  not  so  inncli  in  connection  with  tracts  as  with  vessels,  which 
ill  iliiir  course  may  pass  tlirouKli  several  tracts,  there  ne«-essarily  w*- 
tiKiiiiiitir  coinliined  sclerosis,  that  is,  a  sclerosis  of  hoth  motor  and 
Hii-(ir\  tracts  coi?irirlently.  In  Friedreich's  ataxia  there  arc  found 
atni|i|iic  tracts  iMtth  ascending'  and  descendinj;  l|M»sterior  and  lateral 
'olmiMi-,  direct  cerehellar,  etc.).  A  similar  state  is  fonnd  in  subacute 
combinjd  sclerosis,  associated  with  peniicions  anemia.  H<'sides  these, 
ill  lathyrism  and  pellagra  an-  fonnd  similar  states  of  comhined  sclerosis; 
llif  lornicr  of  fluM-  follows  the  |)oisoninj;  hy  several  kimls  of  vetch 
l:itliyriis),  and  the  latter  is  commonly  attributed  to  a  diet  of  mouldy 
ni,ii/c.  though  there  is  still  nmch  discussion  upon  this  matter  of 
<;ii|sitinn. 

Progressive   P-'hances.     Associated   with   the  low   rt-generative 

|"A\<Ts  of  the  11  li .  tissues  hy|H'r|)lastic  chanties  in  the  cord  are 
ili-tiiK  ily  rare.  As  ii>cards  the  tumors,  the  gliomas  an-  the  only  ones 
Miliii  icntly  common  to  deserve  note.  These  ;;liomas  oripmite  most 
"Itcii  in  tlic  immediate  neij;hliorhood  of  the  central  canal,  and  frecpiently 
iirc  (lilliise,  hcinj;  of  the  nature  of  jjliosis  rather  than  sharply  defineil 
^.'li'iiii.i.  If  tile  central  jjlionm  breaks  down,  a  condition  of  syringo- 
iMMlia  i^  produced. 


THE  MENINGES,  CRANIAL  AND  SPINAL. 


The  Dura  Mater 

Circulatory  Disturbances.  -The  most  imjiortant  circulatory  disturh- 
"1"  ~  <if  the  dura  arc  thrombosis  and  hemonhages.  With  tiie  dura  are 
iii'.-.,iril.\  to  he  included  the  remarkable  sinuses  of  the  cranium,  for 
fill-.-, ire  formed  in  the  substance  of  the  dura;  by  their  situation  and 
"I  i~f  tiity  arc  peculiarly  liable  to  be  the  site  of  thrombosis,  rather 
tr  ■  :i  the  .kiill  thaii  from  the  firm,  resistant  dura  itself. 
Thrombosis.  Thrombosis  may  be  traumatic,  marantic,  and  infective. 
ii'  iiiMniiitic  form  is  occasionally  met  with  in  cases  of  chronic  exhaustive 
ill  '  iM-  iissociatc<l  with  cardiac  weakness  and  slowed  circulation,  most 
iii't  in  the  longitudinal  sinus.  It  is  by  no  means  clear  that 
iiii  the  somewhat  allied  form  occasionally  seen  in  chlorosis,  may 
'  'I'l.  iictnally  to  infection  of  a  low  grade.  There  is  s<mie  tendency 
'■'  rcijiinl  all  iK.ii-trauinatic  thromboses  as  infective.  Infective 
i"  !-.  especially  of  the  lateral  sinus,  is  the  most  important  of  all 
'"iilitioii-.  and  most  often  arises  l)y  extension  from  inflammatory 
I  111  the  mastoid  cells,  either  directly  i>r  b\  way  of  the  emissary 
It  lie  petrous  bone  or  in  the  cranial  vault.     The  cavernous  sinus 


ntti   I 
flii- 

IlKl      i 
lllr 

I'-,: 

II,.-. 

I" 
\l 


502 


THE  SEHVOUS  SYSTEM 


is  less  often  thrombosed  by  extension  from  the  orbit,  or  elsewhere. 
The  sinus  is  distendetl  by  a  clot,  grayish-pink  to  dark  red,  firm  or  softened 
according  to  its  duration,  and  at  times  even  appearing  as  little  else 
than  a  purulent  mass.  Such  a  sinus  thrombosis  may  spread  to  a  sur- 
prising extent  into  other  sinuses,  and  into  the  jugular  veins.  The 
results  of  this  softening  are  very  frequently  tlie  development  of  multiple 
abscesses  in  the  lung  and  pyemia,  not  to  mention  the  more  local  develop- 
ment of  meningitis  and  cerebellar  and  rerebral  abscesses. 

Hemorrhage. — It  will  be  recalled  that  the  arteries  run  on  the  external 
aspect  of  the  dura;  thus  while  there  may  be  small  capillary  hemorrhages 
in  the  substance  of  the  dura,  any  large  hemorrhage  brought  about  by 
traumatic  or  other  rupture  of  branches  of  the  anterior  or  middle  men- 
ingeal arteries,  is  situated  between  the  dura  and  the  skuH;  despite  their 
extradural  position,  such  may  naturally  bring  pressure  upon  the  under- 
lying brain  substance  (cephalhematoma  internum,  contrasted  with  c. 
externum,  under  the  scalp).  Subdural  hemorrhages  originate  from  the 
vessels  of  the  pia-arachnoid.  The  same  principle  obtains,  mutatis 
mutandis,  in  connection  witli  the  spinal  dura. 

Inflammation. — Acute  Pachjrmeningitis  Externa. — This  inflammation 
of  the  outer  surface  of  the  i  ura  is  practically  always  secondary  to  infec- 
tion of  the  skull,  the  sii'iwt  ,,  or  the  vertebrae,  or  follows  infected  wounds ; 
it  may  be  of  any  dogin  up  to  abscess  formation,  and,  by  the  firm  con- 
nection betweei  dura  and  bone,  is  localized,  since  extension  is  only 
obtained  at  the  price  of  stripping  off  the  adherent  dura  or  burrowing 
into  the  resistant  bone. 

Pachymeningitis. — It  is  not  a  little  interesting  to  note  that  inflamma- 
tion of  the  pia-arachnoid  may  progress  with  little  evidence  of  involve- 
ment of  tlie  dura,  wliile  contrariwise,  the  curious  condition,  pachymenin- 
gitis hsemorrhagica  interna,  affords  at  least  in  its  early  stages  a  picture 
of  involvement  of  the  dura  alone.  In  this  relationship  or  want  of 
relationship  we  may  recall  that  the  blood  supplies  of  dura  and  pia  are 
from  entirely  different  sources,  and  presumably  thus,  in  connection 
with  inflammation,  the  infection  may  travel  by  one  and  not  by  the 
other.  In  pachymeningitis  lia;morrhagica  interna  the  earliest  stage  so 
far  recognized  is  that  of  areas  of  the  inner  surface  of  the  dura  covered 
by  a  thin  layer  of  fibrin.  What  is  the  cause  of  this  phenomenon  we  d.) 
not  know,  but  we  suppose  that  there  has  been  a  hemorrhagic  oozing 
of  exudate  from  the  finer  caj)illaries  of  the  dura.  The  conditions 
in  which  this  is  found,  viz.,  in  alcoholics  and  the  insane,  does  not  help 
us  to  determine  the  etiology.  Studies  of  cases  of  longer  standing  give 
evidence  that  with  the  organization  of  this  first  deposit  the  newly  fornitd 
capillaries,  originating  from  the  dural  vessels,  again  aft'ord  a  heiuor- 
rhagic  exudate,  wiiich  once  more  exiiibits  fibrin  formation  and  organiza- 
tion, and  in  this  way  in  the  course  of  months,  there  develops  a  thicktnwl 
layer  of  new  tissue  wiiich  may  attain  considerable  depth,  and  by  its 
pigmentation  indicate  that  there  have  been  recurrent  heraorrli;!;;i5. 
The  outer  side  of  the  dura  is  not  alfected.     This  layer  of  new  tissue 


.iMP5K-'5.'««'».i>' 


THE  MENISGES,  CRAMAL  ASH  SPIXAL  'm 

MiM>  exteiKl  over  the  larger  portion  of  thedural  lining  of  the  skull,  and 
m  many  cases  may  show  little  evidence  of  extension  of  the  inflammatorv 
pro<ess  nito  the  pia,  there  being  no  adhesions  to  the  underlying  brain 
snl)staiice,  though  in  other  cases  these  adhesions  are  so  extensive  and 
(OS,-  that  It  IS  impossible  to  think  that  the  pia  has  not  entered  into 
the  process,  even  if  secondarily.  Whether  pachymeningitis  is  trulv 
iiiHaiiimatory  must  be  left  an  open  question. 

Pachymeningitis  CervicaUs  Hypertrophica.-This  disease  attains  im- 
IHirtance  only  because  it  may  lead  to  so  extensive  a  thickening  of  the 
^tr.l(•tllres  around  the  cord  in  the  important  cervical  region,  that  the 
M<r\  ("s  are  implicated  and  compressed  as  they  leave  the  cord.  The  new- 
torin...!  layers  may  extend  as  a  collar,  three  or  four  inches  wide,  and  very 
t hick,  anmnd  the  cervical  cord;  the  cord  may  be  so  compressed  that 
.(•K'eneration  occurs,  and  the  vessels  so  obstructed  that  the  cord  softens 
Ihf  i;n.eral  opinion  is  that  this  is  a  syphilitic  manifestation;  it  may 
rtciuire  years  to  develop,  with  periods  of  quiescence. 

Tubercidosis.-This  arises  chiefly  from  tuberculosis  of  the  pia-arach- 
Mowl.  or  ,.f  the  bone;  the  latter  is  more  common  in  the  cord  by  extension 
ot  h.tts  disease.  There  may  be  gross  conglomerate  tuberculosis  or 
Miiliary  tubercles. 

Syphilis.— This  may  appear  as  gumma  or  as  a  diffuse  process,  and 
my  hv  an  extension  from  disease  of  the  pia-arachnoid  or  from  gumma- 

o,.s  canes  of  the  skull  or  vertebrse;  this  latter  condition,  thanks  to 
iH'tti  r  treatment,  is  today  rare. 

Progressive  Changes.-Tumors.-These  are  essentiallv  of  the  con- 
".<tnr  tissue  and  endotheliomatous  type.  The  so-called  osteomas 
''f  t  ir  .lura  are,  strictly  speaking,  osteophytes,  showing  no  inherent 
t.M.I.M, y  to  grow,  but  are  plaques  of  osteoid  tissue  of  metaplastic 
"n-in  iroin  the  connective  tissue.  Chondromas  are  rare.  Pure  fibromas 
aro  at  tunes  recognized  but  the  small  benign  tumors,  s(,litarv  or 
"iult.pl,.  attached  by  a  broad  base  to  the  inner  aspect  of  the  dura 
|.re  ^trntly  endotJieUomas,  originating  apparently  from  the  endotheliai 
"i"';r  layer  of  this  membrane.  In  general  these  are  firm  and  on 
Mvt,„n  exlnbit  a  framework  or  stroma  of  fibrous  tissue  in  the  meshes 
"t  ^vimh  are  more  or  less  abundant  cells  of  endothelial  tvpe,  arranged 
-m vntrually  after  the  type  of  the  endothelioma  proper.   Whether  the 

;n.^    issue  .s  truly  a  stroma  or  is  to  be  regarded  as  a  metaplastic 

i    ;'  ';  tl'^ndothehal  ces  is  debatable.    On  section  through  these 
-     Iny  have  a  '  s  ui.ly'  fee  ,  an.l  microscopically,  there  are  found 

"r,  ,,   l,.ss  abundant  globular  bodies  with  concentric  striation,  calci- 


I  li.'^e  are  the  psammoma  bodies,  and  when  this  particular  form 
■  n.  ration  ,s  present,  the  tumor  as  a  whole  is  called  a  psammoma. 
"■  npeat,  is  an  endothelioma  with  calcification  of  its  more  central 

'  'I  cells. 

'  from  these  small  firm  tumors,  we  occasionallv  find  larger,  more 
-imors  up  to  the  size  of  an  orange  or  larger,  which  are  more 
'  'i.lothehomatous,  or  have  the  characters  of  a  roun.l-eelled 


504 


77/A'  XEIiVnCS  SYSTE.\f 


1' 


sarcoma;  or  again,  wo  find  (liffusi-  growths  of  eitlier  endotheliomato 
or  sarcomatous  naturt'  s])rea<iinn  over  a  larjit-  art-a  of  the  inner  aspt 
of  the  (inra.  These  larger  growths  naturally  eonipress  and  prodii 
atrophy  of  the  underlying  hrain  suhstaiur.  I'ure  sarcomas  do, 
course,  arise  from  the  sul)endothelial  i)art  of  the  dura,  and  these  a 
usually  spindle-celled. 

There  may  he  tumndurii  sarcomatous  and  carcinomatous  tumc 
affecting  the  dura  mater;  this  secondary  involvement  is  probably  mc 
common  in  the  spinal  than  the  cranial  dura,  and  it  has  been  observ 
that  mammary  carcinomas  are  liable  to  afl'ord  metastases  either  in 
the  vertebra-  or  directly  into  the  dura,  which  growing  are  apt  to  larg« 
fill  the  spinal  canal  and  compress  the  cord. 


v.;     i 


The  Pia-arachnoid 

Anatomically  a  distinction  is  made  between  the  arachnoid  and  pi 
pathologically  no  such  distinction  can  be  made;  in  other  words  the  pi 
arachnoid  may  be  regarded  as  a  loose,  abundantly  vascular  membrai 
(covered  on  its  dural  aspect  by  a  simjjle  layer  of  cells)  in  the  mesh 
of  which  are  abundant  and  large  spaces  lined  by  endothelium,  tl 
arachnoid  spaces,  and  ir.  these  spaces  there  circulates  the  cerebr 
spinal  fluid.  The  vessels  of  this  membrane  give  off  branches  whi( 
l)enetrate  the  brain  substance,  and  it  enters  the  ventricles  as  the  choro 
plexuses. 

Circulatory  Disturbance'^  -  Anemia  is  brought  about  in  a  general 
a  local  way,  the  latter  as  in  hy(lrocej)halus  internus.  Active  hyperem 
is  not  easily  recognizable,  because  the  richness  of  the  vascularity 
the  brain  in  the  corpse  is  so  \ariable,  the  blood  easily  draining  away 
the  tliorax  has  been  opened  before  the  cranial  section.  Passive  co: 
gestion  leaves  its  marks  through  the  dark  bluish  color  r,  '\e  congcst( 
vessels.    (Edema  is  not  unconunon;  it  may  be  conij  .  y  (hydro] 

ex  vacuo),  where  there  has  been  atrophy  of  the  I 
congestive,  as  in  the  newborn  in  cases  of  prolonge 
presentation,  or  hydremic  as  in  nephritis,  or  inflamu.a 
with  acute  infections.    Hemorrhage  may  be  traumatic  or  may  occur 
the  hemorrhagic  diseases,  in  rupture  of  aneurysmal  dilatations  of  tl 
vessels,  or  in  severe  infections;  blood  may  appear  in  the  arachno 
spaces  by  extension  of  hemorrhage  from  the  brain  substance. 

Inflammation.  Leptomeningitis.—  This  may  be  serous,  fibrimui 
purulent,  or  a  combination  of  these;  or  in  more  chronic  infection 
tuberculous  or  diffuse,  as  in  syphilis. 

Acute  leptomeningitis.—  The  serous  form  is  characterized  by  tl 
inflannnatory  a'dema  just  mentioned;  it  is  sei'u  particularly  in  yomi 
individuals  as  the  result  of  acute  infections;  at  times  the  rapid  acciimi 
lation  of  the  fluid  leads  to  ])ressure  symptoms  and  even  to  optic  atroph; 
It  is  also  seen  as  an  early  stage  of  cases  that  are  destined  to  bmim 
purulent.     More   striking   and    more   severe   in  their  effects  arc  tli 


ostance,  i 
.  with  hcii 
\',  associatt 


%>^s^^.s^^'^>i¥w^!i^.  c'-i^:^:- 


lfeLijr'^K5&"^*«--ni6f  "--^^ 


rf9^ 


lu'liomatous 
tiiHT  aspect 
11(1  produce 
nias  do,  of 
(1  these  are 

ous  tumors 
ibably  more 
en  observed 
either  into 
)t  to  largely 


lid  and  pia; 
rds  the  pia- 
•  membrane 
the  meshes 
helium,  the 
he  cerebro- 
iches  which 
the  choroid 

L  general  or 
e  hyperemia 
scularity  of 
ing  away  if 
Passive  con- 
e  congested 

•y  (hydrops 
ostance,  or 

with  ht'iiil 
,  associated 
ay  occur  in 
tions  of  tiie 
i  arachniiid 
nice. 
,    fibrinous, 

infections, 

;ed  In'  the 
y  in  young 
(id  accutnii- 
tic  atrophy- 
to  bcn»me 
cts  arc  the 


THE  ME.\lNGE,<i,  CfiAMAL  AND  .SI'JAAL  505 

ditlcn-nt   ,„n.litio„s   of  suppurative   meningitu.     Main-   agencies   can 
c|.usc    his,  no  ably  the  meningococrus.  pneumocKrus.  strep  ,-  a 
s  nphyiococc-i:  bacdlary  forms  are  not  so  common;  influe  iza  is  perhap 
t  .■  "...St  Irecpient,  1     typhosus,  IJ.  pyocyaneus,  B.  c-oli  and  Te vera 
|.t  ..Ts  are  occasionally   recorde.l   as   lea.ling   to  this  disease      Sud 
■ntcctions  may  be  either  hematogenous  or  by  Extension  algXhS 
>I-rs.  as  from  the  middle  ear.  the  nasal  passages,  the  orbit   etc 
.to  a  h.v  years  ago  conditions  like  epidemic  cerebrospina  Imeid. I 

ii"   "'tSt^^  "''"'"''^r'=  "^  '""^'""'«  amountof'proof  tcZ- 

m  ...t.^  that  they  are  secondary  to  growth  of  the  specific  organism's 

■  upper  nasal  passages.     There  are  two  areas  which  are  especiX 

labl,.  to  be  the  seat  of  purulent  accumulations,  viz.,  the  base  of  the  bra  n 

::;;;;:  ;;.;:r""T"h""'"""  f™.*?.  «-«  the'vert'ex,  over  one  oMo 
Hun  pheres       The  pus  is  specially  apt  to  lie  along  the  superficial 
c>>cl..  „,  the  sulci,  but  may  be  so  abundant  as  to  form  a  thick  kver 
Md.ng  all  the  convolutio..s  of  the  hemispheres.     In  general,  owing' to 
tree  .onnnunication  along  the  arachnoi.lal  spaces,  this  purdent  flu  d 
.  xtjiMls  down  the  cord,  where  it  is  apt  to  accumula  e  aloiwhe  anterio 
jHMl  posterior  hssures     The  ventricles,  also,  mav  be  sinlrK  rnvaded 
.    .•xtens,.,,.  along  the  choroi.l.     A  local  meningitis  mav  arise  efthe 
t   ison  from  without,  as  in  mastoi.l  disease,  or  from  within    he 
I.  as  in  abscss.     It  may  be  laid  down  that  through  the  intimate 
.'— t.on  ot  the  vessels  with  the  cortical  substance,  the  out^    l^s 
'■  «n.y  matter  are  apt  to  be  involvcl,  so  that  ^.e  .leal  T^re  ,  ten 

■I     "uit  that  we  owe  the  pareses  and  other  nervous  phenomena 
tiM    irocn.     hemselves  after  the  acute  attack  has  passe,l  bv 

hhS?!  !«P*«'«eni««fitis  presents  itself  as  a  milky  thickening  of  the 
•-      ii    c    ,v      tv'rr  '."•■^''^''-hood  of  the  superficial   vessels 

'I-  '-      .f     u  I  ;.,!      f  ^T"     •■  "  ^'•'Vr''■'''"*'  K^''«ti"""«  material  at 
'I'"  '1  a.i    •       er      e  f''""?^""";  *'•''""'"">'  '"  ^''^^  "''^  «"<'  the  alcoholic, 

"•  '"   •  u     m;;rH  .Sit"  m    ""  "'•  1  "^"*'"  '"""'"'""tion,  there  ^re 
j^^^    _     l'-'-mt.r.d  .lefinite  ftbrous  adhesions  between  the  dura  and 

"'^'''^■;X^'  commonest  forms  of  meningitis,  aiul  then 

-      m'J^^  '!•''• ,  "':':^^; 7"-^^  -^  the  tuberculous.     This  shows 

.     .  T      OS  s   '  .^, "  ".'"^^"*'''f"."  "' P«rt  of  a  general  hematogenous 

■       ••   ,  .Jh;;^    •«  recogn.zable  on  careful  examination  bv 

"along  the  vessels  of  the  .Sylvian  and  other  fissures  anil 

I;;      n  .Jexiis  ,>f  minute  pi,d,ea,l  and  smaller  tubercir^lllch 

.'parent  It  a  .rnall  piece  of  the  arachnoid  be  floated  out  in 

-    «xan,,ne,I  with  a  hand  lens.     Other  favorite  si  el  are  ovir 

-.1  on  the  apposed  surfac-sof  the  c-erebellum  and  the  tempor" 


it- 

iiii 
tl), 

of 

l„, 

til, 


i-3'-.4S?.v  •■  -aaiL^ic '  -^? 


50G 


THE  SERVO  us  SYSTEM 


ill- 


:# 


'i :     i 


sphenoidal  lobes.  More  rarely  the  tubercles  instea.l  of  being  generaliz, 
may  be  few  .n  number  over  a  small  area,  e.  „.,  of  the  cerebrum  Tl 
appears  to  bo  an  early  stage  of  the  cerebral  ir'  cerebd  ar  tube-ulom 

diffit^^fl  '''T  '"'■^''^"  ™'^'^'  '^PI'^'^^  '•^''^t'^^'y  healthy  and  free  fro 
diffuse  mflammation  one  may  disc.ver  on  lifting  the  brain  that  al  Itl 
nitersfces  at  the  base  are  filled  by  a  yellowishf  gektS  tran^ce 
and  oedematous  n.ass,  really  the  swollen  and  ii^U  at  d  aSaet 
In  general,  the  basa  areas  are  the  m.)st  involved,  and  it  is  o  be  reZ 
bered  that  m  practically  all  eases,  there  are  he  e  n.  onlf  the  mS 
tubercle,  but  s.gns  of  exudation  and  increased  presence  7lymDh™ct 

'"slnl^'"TT'  r^  "^■''"^'^  n-nonuclear'cellsrtheC  stage' 
Syphilis.-Wahzed  gummas  of  small  size  may  be  formS  in  th 

^ZFa  "•  '\  ^r'J^^  of  a  greatly  -thickened  mSg  of     1 
arachnoid,  m  which  the  individual  gummas  are  not  to  be  distin 

^v2  •  ♦  1  v^  '^f .''?''  '^''''^°"'  ^^"f«s-  More  typical  of  cerebra 
syphilis  IS  the  diffuse  thickening  of  the  basal  meninges  with  firm  adhe 
Thk  r  "  ^T  f^?'^'\'''  «n'J  thickening  along  the  basa  nenes 
This  process  of  syphilitic  infiltration  around  the  vessels  w;th\r=^Ki 

:ut:rs^feT";sr%f  TT '-  ^^^'^^^^^^^ 

may  be  ?I  .^l?'  f^'-      T'"'''  ^^''^  ""'^'  ''«"  "^  «>'PhiIis  in  the  craniun 

Pro^esZ^  "  «^  mesarteritis  of  a  single  superficial  vessel, 

sion X!rT  5^«!--Sniall  plates  of  metaplastic  ossification  occa- 

ii«     p     ',  ™'*  "'  the  leptomeninges  as  in  the  dura, 
the  lZ™«   /'  •'  '"'"""^  ^^'  ^""'^"  t"™"'-^  a'-e  to  he  encountered 
commT^'  f*"*™''"**^/  ""d  lymphangiomas,  as  also  flbromas.    More 
common    and    more    characteristic  are   the   primary   endotheUomas 
hese  are  of  two  mam  types:  the  more  frequenUs  compose! TwS 

endotiiehom«;  the  other  form  shows  cells  of  a  more  cylindricTlT^i 
and  penthehomatous  arrangement.  These,  it  is  supposed  are  srictl^^ 
lymphangi<«ndotheUomas.  Both  forms  ar;  aptTTw  transS^ 
Hito  niore  purely  sarcon.atous  growths,  though^occasirafpure  S 

h  "SnieTo'J'^irt/"  '"  ""'l-    ^".— 1  tumor  found  espedalfy 
K  r    V      *'•';  P''""  '"''t^'"  '^  the  true  cholesteatoma,  in  no  wise 

to  be  confounded  with  the  cholesteatoma  found  in  the  mTddle  Tr 
.lhe.e  tumors  form  pearly,  multinodular  masses,  occasionaly  reach: 

Scu'iaT :  'th  "b"  '^ -p'".  '''''''■  "^^  ^^""'^  orvrti^Shrpi . 

SbnalLvlrtl'  '  /"u*  '  'T''''.  "^  '^'^  P»"«  «"J  ^^dulla,  and 
occasionally  over  the  cerebellum,  choroi.l  plexus,  or  cord.    They  are  to 

h  vXke'n  "  n 'T""  ?^"°"'^'  ^'"^  '"^-^-"t  to  their  iSon 
of  CD  ttoM  .  ^'"^*«'""tous  growth.  The  cells  composing  them  are 
ot   epithelial    nature    containing  keratohyaline  granules:   the   nearh 

SsXn  'i''"" '"  ^'''T"^  ^^""'  '^  ^^^"«  coiftaining  fat  and^a  -l 

ai  d  lien.  i"'  .  "  ^''""  T  ''^''''''''  »'«^  found  hairs  in  these, 
and  sebaceous  glands  ha\  ;  been  detected. 


|p,>-m?^' 


PElilPUERAL  NEUVES 


507 


PERIPHERAL  NERVES 

unl'lL'TiTLdrtirr  ^  ^'''^'"^  ^"*"  *"^  systems-the  somatic 
and  tilt  s>mpathetic,  the  former  are  composed  entirely  of  mediillateH 
.u■^^  ..s  and  have  a  somatic  distribution  to  the  voluntarv  muscle  and 
skn  the  atter  are  composed  of  fine  medullated  and  of  non3uTlat">d 
•    I    r=  their  hbres  innervate  the  non-striated  muscles  of  the  bSv 

b  n  e  aborate.1.  Briefly  we  may  say  that  the  nonlmedullated  efferent 
h  ers  take  origin  from  the  lateral  horns  and  pass  out  bv  the  ventral 
ro  ot     o  a  series  of  vertebral  ganglia,  where  either  they  eifd.  or  pass  in  j 

11  tinpnS,  «^  •  1  ^  '''''*^  ^''"^'  ''"em  to  these  fibres,  but  we  may 
<listingni..h  a  cervical  group  in  connection  with  the  superior  cervS 

.^i'tifini'^mSLTarr"*'"^-'^^"-**^^  «^^^  doUir^he^rJ 

fourth  sami  ''"''  originating  from  the  second,  third,  and 

tlL"  ;,r'J^-^  f^''  ''''  ^''^'^^  -"'^•tions  that  m  "  aff  c^  t" 

.lo  not  lenHw         •        '    impulses  which  under  normal  conditions 
rHVrred    o  ^as  of  th-  --  *'  ''         '"'■  ""^  *^'  sympathetic  is 

i,r.„in,    ;    1  I   ,  r""'^ '"  *^«  "'^renaJ  medulla.    We  can  that  is 

-a,.nu.nts  ""*  P^'P^'"^  "'  y«t  t«  formulate  any  general 

n.- •r:fm"i;j];nrinlm'*  J^  ^T  '°^^^'^'  ^-P'^^'^^-  ™e 
"■  i-licate  Tro  1  i;^S„es  '5'L^^^^  ^''^J-'jft-  this. term  is  used 
i«tter  n.ferred  to  L  rhS' ^- u  V  *'^^  so-called  optic  neuritis  is 
-  rve,  leach,  g  to  atr'htT  ^.^  J*  'l^  disturbance  of  the  optic 
^^truction  oVthf^eS;^'S'^!-".^•"*  ^/  "^t^^^-'ial  pressure  and 

^Similarly,  alco- 


v.™,.H,,,:s';i.rvS,°s'-SSl^'r 


TiOS 


TIIE  SKliVois  SYSTEM 


n.\ 


hohc,  arser.c.  a.i.l  ead  neuritiB  ar,-  ^vi^vxxvr.yXnv  rather  than  i.iflainmat. 
states.  In  -e,.-!!!  .•  aute  neuritis  the  peripheral  nerve  trunks  affect 
are  swoue-i  ...  ,1  e^.n^.-sted.  n..t  necessarily  along  their  whole  length  h 
f..r  a  l»n^'.r  .,  short.-  .'.stance,  so  that  they  nu.y  present  spindle-li 
swcil.nKs  a.onp  tiie.r  course.  In  such  cases,  there  is  an  exudati 
..to  the  cnnective  tissue  of  the  sheath  affecting  the  end.H.  per 
a.u  ep.neurium.  ^^.th  this  there  may  he  more  or  less  leukocvl 
nrhl,  ation  j„  extreme  that  there  may  at  times  he  actual  pus  formaii. 
«.th  or  without  localized  hemorrhages,  and  where  the  inflaminati. 

the  medulla  and  also  of  the  axis  cylinders.  Purulent  inflammati, 
of  nerves  usually  occurs  by  extension  from  neighboring  tissue  Sue 
acute  neuritis  may  be  followe.1  by  c-onnective-tissue  overgrowth  whic 
in  Its  turn  by  pressure,  favors  degeneration  and  atrophv  of  the  include 
axis-cylinder  processes.  .Such  neuritis,  besides  being  of  infective  origii 
may  be  traumatic,  from  wounds  or  compression. 

One  of  the  infective  granulomas  stands  out  i)reeminentlv  in  its  liabilit 
of  t"h?l  r"'  ?''  I"''-^-^'-^T-^«P'<«y-  ^'t""erous  peripheral  nerv. 
^rowt)  ;•  I'  '^' f '"'  "*•"  n'  r^"""  ''**^'""^''  '"'■"'^■'•^  by  granulomatoi 
fiS  :.;  n  '""f  '■'"'.  ^■'";t»"»"K  t'»«  l>«^i"i.  and  bring  abot 
anes  hesia,  pallor,  and  atn.phy  of  the  regionr,  of  supplv.  so  that  fingei 

sc  i  ''n '  rf "  "  """  1  "'rV  *''"."^""''"'' ""''  'J'"''  "«■'  '^'^^••"K  ^'^tensiv 
«s  f ;  •/  «u"-f"f-  'f  *  "■'  '■'"■""'^  '"■"^•^■'^^  "'  t*'«  "erves  is  see, 
as  fusiform  fibroid  thickenings  ^long  their  course.  Tuberculosis  o 
peripheral  nerves,  while  it  occurs  with  similar  distal  degeneration  i 
comparatively  rare  Lntil  salvarsan  came  int..  frequent  employmen 
the  effect  ot  syphiJis  upon  the  nerv'..s  was  overlooked  by  most  path 
o  ogists,  but  syphilis  IS  now  held  responsible  for  a  large  number  of  .lis 
turbances  of  the  ..ptic  an.l  au.litory  nerves  which  mav  appear  after  th. 
use  oi  salvars.-,.,  .nd  mon-  rarely  of  mercury.  The  attention  .Iraur 
to  this  subject  has  shown  that  lesions  ..f  these  two  nerves  are  imt 
uncomm.m  in  the  course  of  untreated  svphilis 

ne?r!f  T*""®  Changes.-  Here  must  be  in.lu.le.1  many  forms  of  s.M-all..,l 
neuritis  from  al...,h.,l,  arse;,..-,  lea.l,  erg.>t,  diphtheria,  beri-beri,  an.! 

mnirrT''*AJ""'"*r.  *"''""  "^  ^'"■^'''''  ""*''"•'»«•  t"  n'''"ti«n  ihe  m„r.- 
l^^/vit        T.       .?'  "i-*;T  ^""'^  "^'*'"*^  '"^^■**  ■■'  ^'haracteristic  selective 
actu.ty      Ihus  the  diphtheria  toxin  leads  t.)  areas  of  acute  degenera- 
tion an.l  atrophy,  picking  out  certain  n.-rves  in  th.-  upper  respirat..rv 
tract,  as  we  1  as  the  vagus,  the  .legen.-ration  of  the  latter  being  the 
cause  of  su.l.len  heart  failure.     Lead  affects  the  innervation  of  the 
extensor  muscles  .,f  the  f.,r..arm  and  K-g.  causing  wrist-drop  and  foot- 
drop.     Alcohol  may  set  up  a  wi,les,)rea.l  polyneuritis,  especiallv  aff.Mting 
the  peroneal  nerves.     In  all  the  above  th.-  .legenerati.m  of  the  periplural 
nerves  ai.pears  t<,  be  primary,  they  being  directly  affected.     What  is 
terme.1  secondary  degeneration  is  seen  in  the  peripheral  nerves  vvlu.se 
cell  bo.  les  have  previously  un.lerg..ne  .lestni.tion,  .,r  which  have  lu .  n 
cut  .)tt  tn.m  thos..  cell  bodies,  as  in  true  Wallerian  .legeneration. 


^^m!\^'':':r.^m^ 


m^ 


THE  EYE 


509 


Projrressive  Changes— We  have  already  referred  (see  j).  24.-))  to 
"false  neuromas"  or  amputation  neuromas,  as  also  to  what  we  have  termed 
neurinomatosis  or  multiple  neurofibromas  or  fibromatosis  (see  j).  247) 
Til.  s(.-(i.lled  elephantiasis  neuromatosa  or  pachydermatocele,  appearing 
a>  a  .onKemtal  atfectioii,  has  underlyiiiK  it  a  great  irregular  thiekening 
..r  the  iier\»-s.  of  the  same  order.  Assoeiated  with  this  is  a  general 
.ieformity  of  the  part  with  thiekening  of  the  skin.  Rarely  gliomas 
have  iK-en  descnhed  as  oecurring  along  the  eourse  of  peripheral  ner\'e3 
aiKJ  still  ni«»re  rare  are  lipomas  and  rhabdomyomas. 

All  of  the  gliomatous  and  nenrinomatous  tumors  show  a  tendency 
toward  a  malignant  metamorphosis,  the  latter  giving  origin  to  spindle- 
jrllcl  s(.inetimes  myxo-sarcomas.  Of  secondary  tumors  carcinoma  has 
Ihtii  deserihed  as  occasionally  ext.-nding  in  nerve  bundles  and  bringing 
iihoiit  atrophy  of  the  same,  but  in  general,  nerves  are  little  involved 
in  secondary  malignant  growths. 


THE  ETE 

Anomalies. -The  eyeball  may  be  lacking  (anophthalmia),  a  state 
winch  IS  usually  toiiiid  in  conjunction  with  other  grave  defects  occa- 
si.Mii.ll.v  there  may  be  found  tissues  that  represent  the  eveball,  -mv\  i„ 
,vrt  other  cases  a  small  bulb  may  be  present  (microphthalmia)  In 
.hthnnt  kinds  of  cyclopean  monsters,  two  eyes  in  a  single  orbit  or  a 
Hii^ic  eye  in  a  central  orbit  are  seen.  The  cornea  may  be  smaller  o- 
larjier  than  normal,  or  its  curvature  may  be  more  or  less  convex  than 
■wTiiiai;  part  or  all  of  its  substance  may  be  opaque,  usuallv  in  such 
states  as  microphthalmia.  The  iris  may  be  absent,  or  mav  lp<-k 
pi;:nui.t  (albinism);  the  lens  may  show  opacity,  or  tissue  strands  on 
til.'  siirtace  may  represent  the  remains  of  the  hvaloid  vessels;  the  lens 
may  1„.  dislocated.  Any  or  all  of  these  different  parts  mav  be  lackinL' 
111  coloboma.  '  "^ 

'  "loboma  is  a  congenital  failure  of  the  cleft  of  the  secondary  optic 
^.H.l,.  to  close,  either  wholly  or  in  part.  This  may  thus  affect  every 
-r  ,,.,v  part  from  the  optic  nerve  to  the  eyelid;  it  is  common  in  the  iri;, 
^ind  IS  tre(iuently  associated  with  other  congenital  anomalies. 

Circulatory  Disturbances.-ConJM«c<ira.-The  cnjunctiva  becomes 
hyperemic  as  a  result  of  irritation  from  a  foreign  body,  from  irritant 
^^1  .-,  ir.,„,  exposure  to  bright  light  and  cold  wind  at  the  same  time,  as 
i~  MTii  in  snow-bhrulness,  from  crying,  from  facial  neuralgia,  and  as  an 
:■"•l^  symptom  accompanying  rhinitis.  Persistent  hyperemia  is  well 
"l-trae,l  in  the  eye  of  the  alcoholic  subject,  .ind  occurs  in  mo't 
'  '  -.s  w  luTc  there  is  constant  eyestrain.     (Edema  of  the  conjunctiva  (and 

<lH'  M.tt  tissues  ,,f  the  lids)  is  seen  as  an  enri^  stage  of  generalized 

^    as.na  m   Hright  s  disease  and  broke      -ompeiK^adnn  of  the  circu- 

"•r>  apparatus.     A  common  cause  of  local  (T>,h:ma  is  the  sting  of  nn 

'   .      Hemorrhages  in  the  conjunctiva  are  the  result  ot  injury  or 


'^^y''!m^m^^^:^Bm 


510 


THE  NERVOUS  SYSTEM 


■4r 


arise  durins,'  the  effort  of  violent  coughinK  or  siiee/.iiiK,  e.s|>eciany  i 
chiMren  witii  wliooping  eoiigli. 

/r/.'*.-  Hyperemia  is  of  importance  as  an  earlv  accompaniment  r 
inflammation. 

CAofou/.— Hyperemia  is  seen  as  an  accompaniment  of  inflammation  c 
the  choroid  and  surrounding  parts,  and  in  its  passive  form,  as  part  of 
general  congestion  of  the  IxmIv  in  general  or  the  head  in  particulai 
Hemorrhages  in  the  choroid  are  due  to  trauma,  and  the  hemorrhagi 
diseases. 

/ic<i/ia.— Circulatory  changes  seen  in  the  retina  are  of  a  good  deal  o 
importance,  especially  hecause  the  function  of  sight  is  readily  affected 
Anemia  is  characterized  by  a  visible  narrowing  of  the  arteries,  wit 
pallor  of  the  membrane;  if  extreme,  the  nutrition  of  the  retina  may  b 
affected  and  partial  or  total  blindness  result  from  its  degeneratioi 
Hyperemia  occurs  as  part  of  an  inflammation  of  the  retina  and  of  sui 
roimding  structures,  or  may  be  passive,  as  a  result  of  general  congestioi 
More  important  is  that  passive  hyperemia  seen  in  cboked  disk,  wher 
by  compression  of  the  central  vein  the  retinal  veins  are  larger  and  moi 
tortuous  than  usual.  Embolism  of  the  central  artery  of  the  retin 
occurs  occasionally,  and  sudden  blindness  with  anemia  of  the  membrati 
results;  later,  severe  degenerations  arise  with  ultimate  destructioi 
Thrombosis  of  the  same  vessel  is  attended  by  similar  results  but  is  le; 
frequent.  Hemorrhages  of  the  retina  are  of  much  clinical  interes 
They  occur  in  systemic  diseases  such  as  Bright's  disease,  diabete: 
and  all  those  diseases  which  are  characterized  by  capillary  rupture- 
the  anemias,  the  severe  infections,  scurvy,  and  certain  other  sevci 
intoxications.  They  occur  also  in  trauma,  and  fairly  large  areas  ( 
the  retina  may  be  lifted  off  the  choroid  (subhyaloid  hemorehage)  wit 
subsequent  degeneration  of  the  part  with  whose  nutrition  there  i 
interference.  Retinal  hemorrhages  vary  in  position,  and  consequent! 
in  shape  and  size.  If  superficial  in  the  nerve  fibre  layer,  they  have 
striate  form,  if  deep  they  are  round  or  irregular.  It  will  be  readil 
understood  that  hemorr'iages  of  the  retina  may  be  accompanied  h 
escape  of  blood  into  the  vitreous,  with  consequent  dimness  of  vision. 

Inflammation. — For  an  enumeration  of  the  agents  of  inflr.mmati()i 
and  their  results  on  the  different  parts  of  the  eye  it  is  hardly  necessar 
to  mention  that  more  voluminous  works  must  be  consulted. 

Conjunctiva.— Apart  from  injury,  exposure  to  bright  light  or  irri 
tating  vapors,  the  use  of  drugs.'such  as  potassium  iodide  and  arsenic 
inflammations  of  nearby  or  related  parts,  there  are  many  bacteria  whic 
cause  acute  conjmictivitis.  The  readiness  with  which  bacteria  can  gai: 
access  to  the  conjunctiva  is  self-evident;  nowhere  else  in  the  body  i 
so  delicate  a  structure  so  exposed.  In  a  considerable  percentage  c 
healthy  conjunctivie,  the  Bacillus  xerosis  and  a  non-pathogenic  Stapln  1' 
coccus  albus  are  found.  The  bacteria  which  most  often  cause  con 
junctivitis  are  (in  the  order  of  frequency  in  a  large  series  studietl  i>; 
our  colleague,   Dr.  Hanford  McKee),  Murax-Axeufeld  diplobacillu: 


iiPPP«| 


THE  EYE 


511 


stitpliylococcus,  streptococcus,  pneumococcus,  Microccx-cus  citarrhalis 
^onococcus,  B.  McKee,  B.  Koch-Weeks,  B.  w.Ii,  B.  influenzae,  menin^ 
(lococcus,  B.  xerosis,  B.  Hoffmann— while  a  large  variety  of  saprophytes 
is  seen,  many  individuals  of  these  last  being  found  in  greater  frequency 
than  some  of  the  pathogenic  microbes  enumerated. 

The  character  of  the  inflammation  varies  greatly  but  is  in  no  way 
liistinot  from  that  described  in  vascular  areas;  catarrhal,  purulent, 
iiiid  membranous  forms  are  seen.  The  severe  degrees  of  inflammation 
lire  apt  to  jeopardize  the  integrity  of  the  delicate  cornea;  the  chronic 
forms  may  lead  to  considerable  superficial  loss  of  conjunctival  tissue, 
the  healing  of  which  may  be  attended  by  deformity  of  the  lid.  Ptery- 
gitiin  is  an  inflammatory  overgrowth  of  the  conjunctiva  upon  the 
eyeball,  of  triangular  shape,  the'apex  directed  to  the  pupil;  sometimes 
It  becomes  quite  well  vascularized,  and  the  superficial  epithelium  is 
|)roliferated  and  even  at  times  folded. 

Chronic  ConjunctiTitia.— The  forms  of  conjunctival  inflammation 
known  as  chronic  are,  in  the  main,  characterized  by  proliferation  of 
the  tissues,  which  appears  as  granulations  varying  in  size  from  those 
just  visible  to  cock's-coml)-like  masses  of  large  size.  The  so-called 
trachoma  is  the  most  important  of  these,  the  overgrowths  being  not 
typical  granulations,  but  small  encapsulated  overgrowths  of  lymphoid 
ami  connective  tissues.  It  has  been  shown  that  the  so-called  "trachoma 
bodies,"  intracellular  Ixxlies  found  in  the  epithelial  cells  in  trachoma, 
are  not  the  etiological  factor.  Parinaud's  conjunctivitis  is  a  rare,  but 
severe  form  accompanied  at  times  by  marked  systemic  disturbance. 
Vernal  conjunctivitis  is  a  malady  of  persistence,  with  annual  exacer- 
Itatioiis,  m  which  the  granulations  are  hard,  composed  of  thickened 
il)itlieiium  and  connective  tissue,  at  times  degenerated  into  a  hya''ne 
mass.  The  infective  granulomas  are  rarely  seen  to  affect  the  conjunc- 
tna.  Tuberculosis  may  spread  from  lupus  of  the  face,  and  syphilis 
and  leprosy  are  known. 

Cornea.— The  process  of  inflammation  in  the  cornea  (keratitis)  has 
already  been  described  (see  p.  134);  from  what  has  been  said  there  it 
\m1I  be  gathered  that  the  collecting  of  lymph  cells  and  the  production 
"t  new  corneal  corpuscles  will  give  rise  to  some  opacity  of  the  cornea, 
"cal  or  diffuse.  This  may  be  recovered  from  and  the  foreign  elements 
l>e  iil)sorbed,  but  on  the  other  hand,  a  certain  opacity  mav  remain 
"r  tlie  inflammation  may  become  more  intense,  with  loss  of  substance 
witlun  or  on  the  outside  of  the  cornea.  Should  this  loss  of  substance 
lit  rei)aircd,  the  connective  tissue  which  performs  the  repair  mav,  on 
tlH  one  hand,  remain  as  an  opaque  body,  and,  on  the  other,  by  its 
"intraetion  alter  the  curve  of  the  cornea,  thus  impairing  its  efliciencv 
■'>■'  a  refracting  body;  vascularization  of  the  surface  of  the  upper  part 
"t  the  cornea  may  occur  in  trachoma,  constituting  pannus. 

Diffuse  parenchymatous  keratitis,  evidenced  by  infiltration  of  the 

-rnca  may  lead  to  vascularization  in  the  mbstantia  propria,  the  forma- 

I  •;■  of  new  vessels  being  deep.    Should  loss  of  corneal  tissue  occur  on 

t  e  surface,  corneal  ulcer  is  the  result,  and  if  in  the  substance,  abscess. 


■n 


i%'ffiYW. 

1 

i 

r 

^B^^H 

■ 

K*  "1 


:)12 


Tin:  SERvnrs  systk.v 


SuppuratiTe  keratitis  idhv  he  phlyctenular,  generally  close  to  the  eorneci 
scleral  margin,  where  riiiiuite  pustules  appear  just  under  the  surfaci 
.apidly  l)reakin);  through.  A  eonsiderahle  number  of  cases  of  sup|)n 
rative  keratitis  are  due  in  part  to  the  ciH'xistence  of  injury. 

Corneal  ulcer  nuiy  (M-cur  with  inHainniations  of  various  intensity 
it  may  arise  in  ill-nourished  children  and  progress  slowly,  or  it  ma; 
he  the  result  of  a  fh)rid  conjunctival  inHamnuition  and  ennle  rapidly 
The  serpiginous  ulcer  is  named  from  the  fact  that  while  the  ulcer  heali 
at  one  part  of  its  ed^e  it  proj^resses  at  another;  it  is  practically  alway: 
due  to  pneumococcus. 

Herpes  f)f  the  corn»'a  may  occur,  associated  with  nuirked  anesthesia 

The  infectlTe  (ranulomas  are  of  eonsiderahle  importance  in  the  causa 
tion  of  keratitis;  the  difVuse  form  is  frefpiently  syphilitic,  much  les« 
often  tuberculous,  but  the  localized  occurrence  of  the  gumma  or  th« 
tubercle  is  rare.  It  was  previously  thought  that  there  was  a  specific 
form  of  keratitis  which  followed  lesion  of  the  fifth  nerve,  but  it  ha> 
l)een  shown  that  this  is  not  neurotrophic,  hut  due  to  infection  becaust 
the  eye  is  less  protected  than  in  health. 

Iris. — Inflammation  of  the  iris  should  always  at  once  suggest  tn 
the  beholder  systemic  disease,  and  in  the  order  of  frequency  is  due 
to  syi)hilis.  rheunuitism,  tuberculosis,  gonorrhea,  gout,  diabetes,  oral 
sepsis,  ami  trauma  overwhelmingly  the  first  two.  Fibrinous  exuda- 
tion from  the  vessels  of  the  iris  blurs  its  bright  surface,  and  with  this 
exudate  there  exists  a  strong  tendency  to  a<lhesion  (synechia)  to  the 
capsule  of  the  lens  behind  it.  T'l'  inflamniiition  may  not  present 
the  fibrinous  form  but  may  be  franki.\  sujjpnrative,  the  pus  lying  in  the 
anterior  chamber  thypopyon);  this  usually  follows  a  wound  that  has 
perforated  the  cornea.  The  Kranulomas  exceptiomdly  show  the  i^ununa 
and  the  tubercle,  usually  being  represented  by  diffuse  jilastic  exudations; 
sometimes  in  the  case  of  syphilis,  small  yellow  nodules  are  seen  at  the 
pupillary  edge,  which  in  late  cases  only,  are  to  be  regarded  as  true 
gumma-. 

Ciliary  Body.  Cyctitis,  inflanimatiou  of  the  ciliary  IxKly,  is  often 
combined  with  iritis,  the  combined  disease  being  iridocyclitis.  The 
symptoms  are  those  of  an  iritis  with  the  achlititm  of  excessive  pain, 
tenderness  in  the  ciliary  region,  an  increased  or  a  decreased  tension. 
and  considerable  disturbance  of  vision.  There  are  different  varietii 
the  simple,  the  plastic,  and  the  purulent.  The  plastic  form,  charac- 
terized by  the  presence  o{  fibrinous  exudate,  arises  from  an  injury  in 
the  danger  zone,  and  is  important  because  of  its  ability  to  set  u;'  a 
plastic  iridocyclitis  of  the  other  eye,  /.  r.,  sympathetic  ophthalmia. 
Such  a  i)lastic  cyclitis,  if  not  checked,  will  destroy  the  eye  by  at'opliy 
of  the  eyeball.  The  sympathetic  ophthalmia  may  arise  weehs.  occa- 
sionally years  after  the  onset  of  c\ (litis  in  the  eye  first  affected,  and  :!-> 
to  the  mode  of  transmission  of  the  uifection,  a  century  has  not  adiicd 
any  certainty  to  our  knowledge.  Purulent  cyclitis,  or  better,  iriil<)- 
cyclitis,  results  from  injury,  an«l  the  iniectiou  sets  up  paoophtbalmitis. 


THE  EYE 


•)13 


III  this  frravf  state,  there  is  su[>piiriiti(.n  un«!  diMiiteKratioii  of  all  the 

)all,  p'lierally  acc«)rii|)aiiif(l  by  severe 


Mitt  iiitcrnai  structures  of  the  eye! 

inlliiminatioii  (.f  the  eoiijiiiictiva  amF  the  soft  tissues  of  the  orbit 
Ihr  mdaiiiiiuitory  products  may  greatly  .listeii.l  the  eveball.  their 
-M ;.p,.  bcit.K  prevente.1  by  the  dense  sclera,  which  in  time  mav  Iw  itself 
rnMlnl  to  the  burstui.?  point,  when  the  contents  escajM'.  Shouhl  the 
.  w  ball  not  l)e  remove.,  there  may  be  a  gra.lual  shrinkinR  of  the  empty 
>Mc.  and  a  more  or  less  solid  mass  of  firm  tissue  be  left  to  represent  the 
tfl..bc  (phthisis  bulbi).  ' 

rAoro/V/.- Choroiditis  is  caused  by  systemic  .lisease,  svphilis,  tuber- 
'iilo-is,  certain  disorders  of  mitrition,  or  a  bacteriemia;  in  other  cases 
thr  .ause  remams  undiscov»Ted.  Sometimes  in  the  granulomatous 
iiit.rtions.and  always  in  the  i)acterieinic,  it  apj^ars  as  an  exudative  or 
a  purulent  inflammation.  These  terms  sufficientlv  exjjlaiii  themselves- 
t  If  .Niidatc  may  remain  upon  the  choroid  or  mav  be  thrown  out  intci 
th.'  vitreous  which  loses  its  transparency  for  the  time  beiiiK;  even  a  mild 
frrii.lc  ot  choroiditis  may.  in  healing,  be  followed  bv  atrophv.  A  sup- 
IMin.tivc  choroiditis,  as  stated  libove.  is  almost  nect^ssarilv  a"forerunner 
i>t  iiaiiophthalmitis. 

Hy  r.  iison  of  the  propinquity  of  the  retina,  this  membrane  is  practic- 
i.llv  ahvavs  affected;  in  the  acute  type,  the  retina  quicklv  .lisappears, 
iMit  in  the  more  shnvly  progressinR  infectii.ns,  the  retina  shows  changes 
I"' iilii.r  to  It.  and  the  disease  is  known  as  choroidoretinitis.  In  tuber- 
'  iiIomn  tubercles  of  miliary  size  are  seen  in  the  choroi.l,  lifting  the  retina 
IT  MP-iT  i.ggregate<l  caseous  masses  may  be  found;  the  retina  is  cloudv 
■•""I  l">(s  Its  distinctive  features  as  a  result  of  anlema  or  exudation 
<J"nl.i.u<i  with  degeneration  of  its  individual  structures.  Svphilitic 
<  li"roi,|uretinitis  is  sei-n  as  a  localized  or  diffuse  process,  the  choroidal 
pnililcration  fiemg  sometimes  extensive. 

AV///U,  -  Acute  retinitis  arises  by  extension  of  infection  from  manv 
"'  III''  al)ove-inentioned  parts.     In  this  condition,  the  retina  is  con- 
;.'<>inl,  .edematous, and  cloudy.     Ai)art  from  these  cases,  a  like  appear- 
.'M-  r  i~  >,.,.„,  „,dH,itive.  not  of  an  acute  local  infection,  but  of  a  svstemic 
^ar,-  s,u.i,  as  Hrighfs  disease,  diabetes,  syphilis,  or  arteriosclerosis. 
'  "   N.>t  named  indicated  by  hemorrhage.     Most  important  of  retinal 
'  ijni-'<-  is  tliat  known  as  albuminuric  neuroretinitis,  a  description  of 
"''I'll  u,||  ,n  ge„..ral  serve  for  the  changes  seen  in  anv  of  these  bodilv 
,1      ■  ■   ^:'«  ".'l.rt'qiifntly  the  retinal  examination,  undertaken  l)ecause 
Ji"  ^  iMnn  ,s  aihng  gives  the  first  alarm  of  the  existence  of  the  disease 
inn   I.  swelling,  dou.liness,  and  lack  of  definition  of  the  papilla;  the 
r>tin.   .hows  pomts,  streaks,  or  flame-shaped  areas  of  hemorrhage 
•re  are m  the  macular  area,  irregular  whitish  areas  formed  bv 
'""Illation  of  cellular  debris  which  has  undergone  fattv,  granular 
';^'Nne  degeneration.     Withal,  there  is  lymphocytic  and  fibrinous 
'""!  into  the  retina,  whose  vessels  appear  engorged  and  tortuous. 
"Mst.nce  of  the  hemorrhages  and  the  whiti^i  areas  marks  the 


ritlii:i 

illlll 

tile 

iir 

exni 

Til, 


stall 


■|  n.  uroretinitis.     ^^  hetJicr  due  to  Bright 's  disease,  diabetes  or  a 


,  ^,  "^3 


514 


riiK  \F.H\(>(  s  s)\-^i i:m 


transitory  alhumirmriu  of  preKiuinc-y   gravidic  neuroretinitig    ;  he  pM-tinr 
may  Ih'  the  same,  bnt    Mic  siihse(|iit  iit   t-mirs*      •   the  \mu<  ess  niav 


reoivr     ,vith  the 


loroi-'-i- 

is  i  .ihs- 
>pacitir- 


be  quite  different;  in  tlie  last  nanieil,  ffe  n-tina  i 
disappt>a ranee  nf  the  alhuniiimrja  after  lahnr. 

When  due  to  sypliili     the  It   ..m  is  that    <f,.rr.  i  to  alxi 
retinitis;  it  nniy  l)e  eon>renitii!  or  aequired,  and  ai-jxars  in 
seeond  stage  of  s\phiii      ii-^ually  in  botli  eyes.    'I'iie  fun 
tiriet,  the  retina  and  t       .lisk  iire  swollen,  and  fine,  dust-hkv 
(cist-off  exudate)  app«-iir  m  the  posterior  part  of  the  vitrrows.  'in  tl 
hein<»rh»»ic  form,     .»-ca!le<l  l^f-ause  the  lu  morrhatfes  are  al>inulaii! 
the  usual  signs  of  -etinitis  ar^    im-sent.  am;    m  adiHtion,  fi  ^i   is  , 
series  of  recurrent  I  -•morrhages,  th<  wh'vle  oft   n  heint   in  ind       ■on  of 
widespread  vascu'      disease  (art«  rioseler<.sis),  an     n  i 
l)ral  heinorrhiige. 

Eegressive  Changes,    '"le  only  regi      !\e  ehasiife^ 
arc  those  observen  in  the  ■  cm.  a,  the  ehon.i  i   th«   retin; 
I  iimea.--\n  the  first,  the  cornea,  there  i>  a  regres-ivt 
IS  called  arciu  senilis.     It  c  onsiNts  of  whitis    ar( 
margin  of  the  ((-ri).  a  al)o\e  and  below,  ultin;   ?<■! 
ver   miniitr  dn.      of  fat  which  lie  in  the  sn    -tantc  of 
far  post  rii  iiy  as  i  Jescemet's  membrane;  son    '  mes  t' 
appears  tc  be  a  kind  of  hyaliie,  whi!-    in  (      ^  r  ca        i       r 
to  be  a  depo-ition  of  lime      Its  m      ctt  -nsparent  tissue  ot  th( 
which  de]"'-inonth».ad\ai     iigdcKenerat       of  the  f  Itxxi  v«  ^sel 
It  is  thus  htii    n'ore  than  a  sign  -4  arteri:'.    age      In  the  choroit 
times  a>    i  >e(jP!"!  to  previous    uHammation,  ar     ^  ot  atropi 

ith  irregular  ],, ^'mentation,  an. I     >metinie-  ull;      tely  e\    ■- 
<i  notion  ot  'one.     In  the  Tctina,  (hsrenerat  i  ve  ■  hanges  oci    '■ 
ol  age,  a>     ell  a>  aft(  r  various  f.rms  of    lis«  ase,  such  j. 
stibretinal  heniorrhag''.     The  nx! 
obscure  fatty  or  other  eliantres. 

;,;m»nt  may  in  Teas* 


rrunn-  m   "<re- 

f  impot    inee 

and  the  ,  ns 

haiige  whicit 


-eeii   . 
aade 
e  corn 
'iti'*h 


1e 


■crea.- 
retina  in  which  the  su}>er     tal  la 
layer  attached  x<>  the  e'    .roid 
chanps  in  the  separat'^     iayi  r 
undergo  maceration  or       ijeiierai 
depo-ition  in  it  of  c{.lca      n.    matert 

Retinitis  Pigmentosa 
mator\  state  of  the  retii 
males,  especifflly  those  wh 


ars 

■a, 

'vors. 

>orae- 

'ccur, 

pio- 

:'SU' 

tis  ai 

uid  cones  niay  atrop  tiderg. 

ysts  may  ari«e.  and  i  tk     .iioiint  w 

-'-  casi     of  separaion  of  the 

away       ving  ■   e  pigment 

»t  ;"  !'     ae     uipanii.i   by  grave 

i  be.      !es  (     "matous  and  may 

of  diii-  rent  kinds,  ev-  n  to  the 


-t^i 


no 


•1     inflani- 

,  aiieets 

Hi  parents. 


ais;-stnr!:     :i      jjressive  J! 
which  of(  iir    ill  particulai 

fe  the  offsprngof  consang  ._  ^ 

In  thi>  rare  disease,  the  roi  a  is  degcficrated  and  atropnied,  and  then 
is  a  migration  or  a  carryin  of  the  i  ,'raent  from  the  external  la\er, 
wher  t  normally  lies,  to  the  inner  ers  of  the  retina,  where  it  is 
depi      ed.     ^Vehave  previi.Msly  |M>i>^       out  that  the  pigment-carr\  in^- 


cell 
sa 


*he  skin  seen 
hat   methoo 


re 

ill 


e  mig        ,y  powers;  it  is  not  possible  to 
''1  -n^   changes  its  situation  in  retinitis 


THE  EYK 


515 


li  tin"  formation  of  f 


t 
has 
lift 

and  I 

illf  IfllS 


'  be  rt>niov«>( 
uch  n  lens  h 
-<■,  remaimd 


!.iu'in«nt«»sa,  but  a  is  laid  d   wn  apparently  in  eiHlothelial  .   \h  in  the 
vicinity  of  blomJ  vessel;-  in  fibrol;c  areas. 

Lnis.    The  r     ressive  .hanges  in  the  lens  that  are  of  importatue  are 
th(.s,  that  give     ^e  to  ojmeity-   in  short,  the  various  forms  of  caUfMt. 
(  iiiFiiet  IS  of  t'  o  distirx-t  f.»rnis    stationary  and  progtMsiTe      In  the 
forup  r.  a  Cfirn.i     inf.    tu.ji  may  leail  to  a  localized  area  <      .paritv 
on  t  ,•  anterior  surfaii    of  the  lens  which  remains  tliruURi       fe,  but 
whi.      IS  of  little  iniiMJrtanre,  Iweause  it  dcM's  not  increase  in    iZe.     A 
hk.        iditioi,     ia\     ifict,  though  more  rarely,  the  pc  -eriDr  surface 
or  a  Mn^i    Ian..  Ila       ih*-  lens  may  Im-  opaque,  and  of    ms  the  extent 
!«■   imiM.rtanee  are  nt.fssarily  Kreater.     Progressive  .atarnet   is   (]) 
■  mi,-.  (2)  congenital  (jn<  .Miile),  and  Ci)  traumatic.     In  senile  cataract 
'iKKt  famili.,r  form      lie  fibres  of  the  lens  undergo  <iegeneratio>.' 
globules  and  myelin.     Isually  the  opaque 
"extraction."     It  may  happen,  further, 
i«en  removed,  the  po  tcrior  capsule,  which 
tay  itself  bi«come  opatjue    secondary  cataract 
pacity  constitutes  capsular  cataract.     In  'raumatic  cataract 
patjue  a,-",  a  direct  result  of  an  injiirv,  ;.,id  here  it  is  that  a 
'ouMderalHc  degree  of  absorption  of  the  opafju.    tissue  mav  occur- 
M"Mld  til.    lens  fibres  b-   ome  separated  and  fb.id  be  absorb^  (from' 
tlir  a(|U('oiis)  the  lens  n.    v  swell  up,  may  be<  .r.,f  soft,  and  may  even 
k'  .oniplet.ly  absorfjed      if  t'„.  lens  and  capsule  become  Hxed  to  some 

il*    zed,  a  considerable  fiJ  -ous  proliferation 
I'T  with  the  new  blixxl     rssels,  constitutes 
-ransparency  of  the  ler        Even  calcareous 
)osited. 

adiva.-  Certain  benign  tumors,  fibroma, 
re  found  on  t!ie  conjunctiva,  but  the 
-t— the  squamous  carcinoma  and  the 
sarcoma.  Carcmoma  is  oltenest  seen  as  an  extension  from  the  eyelid 
"r  utli.r  nciirby  .structure.  Sarcoma  is  less  common,  and  when  it 
"< '  Mrs,  may  be  of  the  pigmented  variety. 

ror//,y,.-  Primary  tumors  of  the  cornea  are  \  erv  rare.     Isolated  cases 
;'i  i.rnniiry  fibroma,  papiUoma,  sarcoma,  and  myxoma  are  in  the  literature 
1   ;      rnctnre  may  be  secon.larily  inxaded  from  other  parts  of  the  eve 
"'•v.    1  igmented  sarcomas  are  found,  bnt  by  ih.  means  so  commoiilv 
ii-   iniilar  tumors  m  the  choroid. 

'//om,f/.-  -The  most  common  progres.sive  tissue  change  in  the  choroid 
^  melanotic  sarcoma,  of  which,  indeed,  it  is  the  most  frequent  site.    Thes. 
tiiii>"r,  are  markedly    pigmented,  consist  of  round  or  .spindle  ce!' 
firov,  rapidly,  arid  having  once  grown  through  the  .sclera,  rapidlv  f( 
I"      '  i-cs.     fhey  are  seen  as  flat,  ses.sile  growths,  lifting  the'reti. 
•>~  '     '  progress. 

Ii     ''IKI 


nearby  structure  an 
ina.\  incur,  and  thi 
a  vtr    ;;reat detrini. 
tnatcrial  may  be  ultin 
Progressive  Changes 
lipoma,  papilloma,  or  05- 
iiii-r    important   an-   m; 


gllon; 


ra 


'.-The  only  imptirtant  tumor  arising  from  the  retina  is  t 
"  ""•    have   nr-  vjoiwly   masle   referpne*-.     The   tun- 

he  globe,  making  its  way  through  it  and  appearin 


•     I 


510 


THE  XKHVOrs  SYSTEM 


m. 


% 


as  a  funjjatiiig  luxuriant  growth  that  sprca<ls  with  ^rcat  readiiies* 
Its  ct'lls  are  small,  closely  paeked,  and  with  special  stains  the  spider-le] 
processes  can  he  demonstrated.     It  occurs  invariably  in  infancy. 

The  Vitreous  and  the  Aqueous.— In  the  foregoing  consideration  o 
the  diseases  of  the  eye,  no  mention  has  been  made  of  the  vitrnons  o 
the  aqueous.  The  vitreous,  it  will  be  recalled,  is  not  a  fluid  but  i 
gelatinous  substance  which,  if  allowed  to  escape,  is  not  replaced,  which 
too,  may  by  injury  become  on  the  one  hand  fibrillated  and  on  the  « thei 
liquefied.  .Should  it  become  fibrillated,  it  is  less  transparent  and  :na; 
contract,  jjulling  with  it  the  delicate  retina  away  from  the  choroid 
By  reason  of  its  position  and  consistence,  the  vitreous  is  the  mediun 
into  which  exudate  is  thrown  as  a  result  of  inflammation  of  the  part 
of  the  eye  in  contact  with  it. 

While  making  reference  to  the  aqueous,  the  secreted  fluid  of  the  an 
terior  chamber,  seems  the  best  occasion  on  which  to  deal  with  glaucoma 
a  very  im|)ortant  disease  which  is  characterized  by  increase  of  intra 
ocular  tension,  with  residtant  pressure  on  the  structures  in  the  eyeball 
(Ilaucoma  may  arise  fnmi  inflammatory  causes,  in  which  case  a  fev 
hours  suffice  for  its  development,  or  it  may  arise  insidiously,  and  Ix 
discovered  only  when  an  ophthalmologist  is  consulted  for  failing  ,  'sion 
or  when  the  patient  discovers  that  one  eye  is  blind.  In  such  a  cas( 
the  damage  is  already  done,  but  in  the  first-named  form,  treatmen 
may  be  cHectual.  The  name  glaucoma  is  given  because  of  the  greenisl 
reflex  that  is  given  from  the  |)upil  to  the  eye  of  the  beholder;  insteaf 
of  a  black  color  of  the  i)upil,  the  beholder  seems  to  see  a  green  color 
the  eyeball  is  hard,  tense,  and  the  cornea  <lull;  the  aqueous  humor 
ordinarily  drained  away  by  the  canal  ot  Schlemm  and  the  space; 
of  Fontana,  fails  to  find  escai)e,  owing  to  blockage  of  these  passage: 
by  narr'>wing  or  obliteration  of  the  angle  of  the  anterior  chamber 
Owing  to  the  great  intraocular  pressure  the  optic  disk  becomes  cupped 
which  cupping,  together  with  the  hardness  of  the  eyeball,  is  suflicieni 
to  distinguish  the  disease. 

The  Optic  Nerve.-  It  is  necessary  to  point  out  one  at  least  of  tht 
l)athological  processes  that  affect  the  optic  nerve.  The  most  importani 
is  choked  disk,  the  name  applied  to  the  pa])illa  altered  in  certain  patho- 
logical states,  as  when  there  is  a  more  than  normal  intracranial  tension 
such  as  is  produced  by  the  presence  of  a  new  growth  or  an  inflammation 
of  the  membranes  of  the  brain.  Some  of  the  names  applied  to  chokcil 
disk,  such  as  papillitis  and  ojUic  neuritis,  imply  that  the  change  i^^ 
an  inflammatory  one,  but  this  is  probably  not  the  case,  although  tlu' 
ai)i)earance  of  choked  disk  is  seen  as  part  of  a  papillitis  or  optic  neuritis, 
(lioked  disk  is  an  a'dematous  state  of  the  optic  papilla.  As  the  ojitic 
nerve  is  contiimous  with  the  brain  substance,  the  cerebrospinal  fluid 
surtaunds  it  in  the  ojjtic  nerve  sheath,  and  may  press  upon  it;  thus  the 
central  vessels  which  come  to  riui  inside  the  nerve  itself  are  likewise 
ci>m|)resser|  and  n-dema  of  the  pajrilla  and  the  most  distal  part  of  tiie 
nerve  results.     In  a  moderate  degree  of  choked  disk,  the  outline  of 


THE  EAR 


r)17 


tl..'  paiHlIa  IS  blurred  and  indistinct,  the  papilla  reddened  and  swollen 
.■>I..c.ally  .„  .ts  nasal  half,  while  the  retinal  vessels  are  enlargld  and 
tortuons  In  more  extreme  cases,  there  may  be  splashes  of  W- 
rn,..  on  the  d.sk.  Should  cedema  persist,  atrophy  of  the  nerve  ft^es 
lit  tiic  disk  may  be  the  result.  "vcnurts 

X.uritis  of  the  nerve  trunk  may  occur  from  an  orbital  or  a  meningeal 
nit.rt.on.  \Ne  have  previously  pointed  out  the  liabilitv  of  the  nen^ 
trmik  to  flbromatosm.  and  true  neuroma  has  been  found  ' 

The  Orbit.- The  eyeball  is  siispen.led,  as  it  were,  in  the  bony  orbit 
jUH  be  ween  the  globe  and  the  bone  there  is,  therefore,  a  coSerable 
l>ulk  of  muscles  and  connective  tissues,  not  to  mention  fatVnd  the 
v.^ular  and  nervous  structures  that  are  placed  there.  Inflammat  on 
<\  tlH..e  soft  tissues  occurs,  as  a  diffuse  ceUuUtis  or  as  abscess,  result Z 
run.  rauma  or  infection;  to  the  latter  the  orbital  tissues  a^e  Scpoed 
tor   .,t«,,„„  may  spread  from  the  face,  the  cranial  cavitv,  the  Ees 

TumoirT     ^''"^""'^  "'  f^"^""^  mechanism,  the  lacrimal  S' 

Tumors  of  many  orders  are  found  in  the  orbit,  apart  from  those  that 

nay  spread  from  the  globe:  angioma,  osteoma,  myoma,  and  teratoma  are 

'-'"•I.  while  sarcoma  is  fairly  common;  carcinoma  is  onlv  seco^darv 

or    y  extension.     Cysts  of  many  sorts,  including  hygrmi  a Tdo^Ks 

<>t  like  congenital  origin,  may  be  seen. 


THE  EAB 

Abnormalities.  -Anomalies  of  the  different  parts  of  the  auditnrv 
'M'paratus  are  numerous,  but  relatively  unimportant jlnsiderSth^ 

;:.:;:;:,"    '^T  '*""*"'!f'  '^r  ^'^--^^  «^-t  '»-  middle  and    ntina! 
•  usually  associated  with  other  defects,  such  as  harelip  and  clef 
It.,  the  auricle  may  be  abnormally  small,  abnormally  large    or 
■i-'.-x.ry  auricles  may  exist.    The  external  auditorv  canal  Zv  Z 
a  sent,  stenosed   unusually  narrow,  unusually  wide  o  ^v^^rduScated 

Ik  ..nun  membrane  may  be  absent  or  flssiied.     The  nifWle  enr  ^ 
I'l  absent   as  may  the  Eustachian  tube,  or  the  latter  mafbecJ^^i 

if    f     ''""l"^'"l'>.^-  freezing  is  well  known.    Hyperemia  is  usuallv 

i^  -"  u  .>:=,!?:*  !^:r'- '--  ""-«^  ^— in  ;C 

t--i">mn  K^S  ^¥^?«*---^:i'-^-"'«tory  changes  are  not  of  impor- 
^^      .  .|IMrt  from  the  inflammations  or  traumas  with  which  they  are 

part,  the  enlarged  individual  vessels  being  visible  in  states  of 


518 


THE  NERVOUS  SYSTEM 


i 


inflammation.    Hemorrhage,  of  punctiform  nature,  may  occur  in 
membrane,  and  may  show  upon  one  or  the  other  side. 

Middle  Ear. — HyDeremia  occurs  as  part  of  the  inflammatory  proo 
and  as  the  result  of  general  passive  congestion  of  the  head  regi 
Hemonhage  is  usually  the  result  of  trouma  or  of  a  particularly  virul 
infection — hemorrhagic  otitis  media. 

Internal  Ear. — Hyperemia  and  hemorrhage  occur  under  conditii 
similar  to  those  in  which  they  arise  in  the  middle  ear,  but  hemorrhi 
is  of  more  importance,  as  it  may  cause  deafness,  and  the  absorpt 
of  even  a  moderate  hemorrhage  may  be  attended  by  damage  to 
delicate  structures  involved. 

Inflammation. — Auricle. — Any  of  the  inflammatory  processes  wh 
affect  the  skin  may  afl'ect  the  auricle.  The  inflammation  which  folk 
freezing  is  familiar,  the  auricle  becoming  swollen,  bluish  red,  and  pa 
ful;  blisters  may  form  on  the  surface,  and  even  gangrene  may  folic 
Inflammation  of  the  perichondrium  or  of  the  cirtilage  iiself  may  acco 
pany  this  or  other  form  of  injury.  Perichondritis,  secondary  to  inju 
as  at  operation  or  after  hematoma,  is  occasionally  followed  by  slij 
deformity  of  the  pinna  which  appears  wrinkled. 

External  Auditory  Meatus. — Inflammation  may  be  localized,  as 
the  common  furuncle,  whose  origin  can  be  readily  understood  when 
is  considered  that  the  wall  of  the  meatus  is  exposed  to  contact  w; 
discharges  from  the  middle  ear,  is  liable  to  eczema,  and  does  not  read 
lend  itself  to  complete  cleanliness.  On  the  other  hand,  inflammati 
of  the  meatus  may  be  diffuse,  from  the  same  causes,  especially  in  patiei 
whose  resistance  is  poor;  secretion  tends  to  form  upon  the  wall,  whi 
is  shed  off  from  time  to  time  and  as  quickly  re  <>ved.  The  infecti 
may  be  confined  to  the  soft  parts,  may  be  supci-ticial,  or  periosti 
and  implication  of  the  bone  may  arise;  in  any  of  these  cases  an  absc< 
may  form.  Membrane  may  form  from  diphtherial  or  other  infectic 
and  mycosis,  or  infection  by  moulds,  is  seen.  The  infective  granulom 
ahect  the  meatus,  tubercles  being  found  on  the  cartilage  of  the  auri( 
or  'n  the  skin.  Syphilis  may  show  itself  in  ulceration  or  in  inflammuti 
of  the  cartilages;  gumma  is  not  unknown.  Both  of  these  infections  ii 
rare. 

Drum  3/e7n6ran<?.-~  Inflammation  of  the  dram  membrane  or  myringi 
is  usually  the  result  of  extension  from  nearby  structures,  especially  t 
auditory  canal.  The  membrane  becomes  red,  swol'"-  soft,  and  evi 
tiny  abscesses  may  be  seen;  in  cases  where  the  n  ■  ■■■  m  ation  persis 
the  surface  may  become  granular.    The  membr  is  been  .sii 

affected  in  both  tuberculosis  and  syphilis,  in  patient.      »o  have  lesiui 
of  these  diseases  in  the  middle  ear  or  other  nearby  structures. 

Mi<i/ile  Ear. — Inflammation  of  the  middle  ear — otitis  media— is 
frequently  found  and  important  disease.  Clinically,  it  is  divided  in 
well-defined  groups,  the  acute  and  the  chronic,  while  pathologi<;iii 
one  may  reoosrnize  a  simple,  often  catarrhal,  and  a  suppurative  fornr. 

Trauma  is  often  responsible  in  part  for  its  origin;  the  infectiw 


THE  EAR 


519 


occur  in  the 


w hicli  13  always  present,  may  come  from  the  Eustachian  tube,  which 
airords  direct  continuity  to  the  infections  of  the  pharynx,  or  through  a 
.laiuaged  membrane,  or  by  the  blood  or  the  lymph.  There  is  no 
specihc  microbe,  for  many  are  effective  in  its  causation 

In  acute  otitis  media  of  a  simple  type,  the  mucous  membrane  of  the 
cuMty  IS  reddened  congested,  and  swollen,  with  an  abundant  produc- 
tion of  mucin  in  which  appear  degenerated  cells  and  a  few  leukocvtes- 
the  submucous  tissue  is  infiltrated  with  cells.    The  drum  membrane 
shares  in  r,he  inflammation,  and  perforation  mav  occur.    It  is  not  easy 
to  draw  a  sharp  line  of  distinction  between  this  and  the  suppurative 
form,  mto  which,  indeed,  it  frequently  passes.     In  the  latter,  the  secre- 
u...  IS  frankly  purulent,  the  inflammatory  infiltration  is  greater,  and 
there  IS  a  greater  liability  to  ulceration  and  necrosis  than  before      In 
considering  infective  diseases  of  the  middle  ear.  we  must  remember 
tliat  the  mastoid  cells  represent  an  extension  of  the  antrum  in  the 
upper  back  i)art  of  the  middle  ear.  and  that  these  cells  are  probably 
involved  to  a  greater  or  less  extent  in  the  acute  process,  although  not 
nect.sar.  y  to  a  degree  which  will  be  evident  clinically.     By  reason  of 
the  sniallness  of  the  outlet  from  the  cells  to  the  middle  ear,  retention 
ot  secretion  in  the  mastoid  cells  is  apt  to  occur,  which  retention  is  largely 
responsible  for  the  cim.cal  signs  of  mastoiditis.    Spontaneous  cure  of 
th..  disease  in  fact,  is  to  be  looked  for  rather  in  the  absorption  of  the 
exn-late  and  the  resolution  of  the  inflammation  than  in  actual  drainage. 
Lx  ensu,n  of  the  disease  follows  the  failure  of  resolution  or  of  drainage 
an.l  tends  to  involve  the  bone  in  the  direction  of  least  resistance,  which 
max  lead  to  extradural  inflammation,  labyrinthitis,  or  infection  of  the 
lateral  sinus. 

A  |)ersistent  infection  without  the  formation  of  pus.  may  be  the 
rcsu  t  ot  a  simple  acute  infection;  the  changes  are  chiefly  of  hyper- 
tropne  nature.  Chronic  suppurative  otitis  media  is,  however,  of  much 
iTcater  importance,  and  should  be  considered  under  two  heads.  In  the 
olnrvL  V^K  ''''"•'j  ?!  ^''"^  ^h^onkity  lies  in  th..  Eustachian  tube  and 
I'M  Nnx,  and  the  middle  ear  is  inflamed  secondarily  by  the  persistent 
;-har,e  passing  through  it.     This  type  is  best  illusirate,!  I,y  fhe  gro^p 

ea^es  winch  depend  for  their  chronicity  upon  adenoid  masses  and 

.1  tonsils.-    In    he  second  group,  the  chronicity  depends  upon 

""iinte  ,)at hological  changes  in  the  middle  ear  especia"v  in  the  attic 

:;.;  nnn,  and  ,„astoid  where  the  lining  of  the  cavitHn.    even  the  boS 

.    Irm.V         -i     l^'^  ^''*"?^  ^^^  ^*'^'  ^^""'^  the  '  .ling  has  become 

n  ..  i,  either  by  metaplasia  or  by  extension  trom'the  external 

"•I'l  TV  meatus,  and  the  formation  of  cholesteatoma  occurs.    Cho- 

-  .a.,ma  is  an  aggregated  mass  of  desquamated  epidermal  cells  and 

-  aoeumulating  from  the  walls  of  the  cavity  which  has  ll^ome 

i  '0  new  squamous  epithelium.    Such  are  the  cases  in  which  the 

tllwnJ  ^r"-"  '"*  *"^  f°"'  ^°lf"'"g-    It  is  especially  in  this  group 

■'in'.'  It  1       •"t^'f^^'V'''  compiiculion  exi  ts  and  the  urgency  of  a 

.'    n  case  depends  largely  upon  the  particiUar  p«rt  attacked  and  the 


--•*     ■:;rt*':i 


520 


THE  NERVOUS  SYSTEM 


I  if 


tenflency  to  retention,  since  retention  leads  to  bone  destruction, 
will  he  understood  that  in  either  of  these  groups  tiie  mucous  racmbr 
may  be  considerably  hypertro[)hied  «\en  to  the  extent  of  i)olvi 
excrescences,  the  ordinary  aural  polyps. 

Chronic  adhesive  otitis  media,  which  is  the  commonest  cause  of  deafn 
IS  known  also  as  sclerosing  otitis,  and  arises  from  the  occurrence 
adhesion  between  tiie  ossicles  and  tlie  walls  of  the  eavitv.  Specii 
important  is  the  involvement  of  the  stapes  in  the  oval  window.  Th 
adhesions  may  be  the  residt  of  a  former  suppurative  otitis  or  may 
of  very  slow  formation  from  long-continued  catarrhal  procosses  in 
middle  ear.  These  cases  are  prone  to  begin  in  childhooti,  at  wh 
time  the  subnuicous  tissues  are  normally  more  abundant  than  in  ad 
life.  With  chronic  inflammation  this  tissue  is  not  absorbed  and  tei 
to  become  organized. 

Otosclerosis  is  sometimes  incorrectly  called  "dry  catarrh."  It  is 
unknown  origin  and  depends  on  change  in  the  labvrinth  capsule  w 
exostosis,  especially  liable  to  occur  in  the  region  of  the  oval  windt 
It  IS  important  when  it  causes  a  bony  ankylosis  of  the  stapes  in  1 
oval  wimlow  itself.  Such  foci  of  disease  may  occur  in  the  cochl 
when  an  atypical  clinical  picture  of  nerve  deafness  is  presented. 

Tuberculosis  occurs  in  the  middle  ear  as  a  somewhat  late  manifestati 
of  a  se\  ere  infection  elsewliere  in  the  body.  There  is  no  special  chai< 
teristic  to  be  noted,  save  that  the  process  is  suppurative  and  attend 
by  a  rather  rapid  necrosis  of  the  tissues. 

Internal  Ear.-  Inflammation  of  the  internal  ear  may  be  said  to 
always  secondary,  either  to  an  infective  process  in  the  middle  ear 
withm  ihe  cranial  cavity.  Extension  commonly  occurs  from  the  midc 
ear  by  erosion  of  the  bony  wall  at  some  point,  or  extension  through  ti 
membranous  closures.  Secondary  to  a  meningitis,  it  may  be  infecti 
by  extension  from  the  internal  auditory  meatus  or  some  of  the  lymphaf 
connections.  This  involvement,  secondary  to  cerebrospinal  mem' 
gitis,  is  perhaps  the  comuKtnest  cause  of  deaf-mutism. 

Regressive  Changes.  J// ric/e.- The  oidy  regressive  change  thj 
need  he  here  mentioned  is  the  occasional  calcification  of  cartilage,  ai 
the  tophus,  a  deposit  of  urates  which  is  seen  in  gout. 

Drum  Membrane.  -Atiophy  of  the  membrane,  with  thinning  an 
consetjuent  increased  transparency,  is  noted  subsequent  to  chron 
catarrhal  states  of  the  middle  ear. 

Internal  A'ar.— Sporaflically  and  in  some  families  there  seems  to  I 
occasionally  a  special  tendencx-  to  degeneration  of  the  cells  of  the  spin 
ganglia,  leading  to  deafness. 

Progressive  Changes.— J  (/rtc/e.— These  differ  in  no  way  from  thos 
occurring  in  the  skin  and  subepidermal  tissues  elsewhere. 

External  Auditory  Meatus.-  Pol\poid  overgrowths  of  the  mucos 
are  seen,  the  result  of  inflanunation;  exostoses  of  considerable  size  ar 
found,   sometimes   pedunculated,  often   sphericol.     Various  kinds  o 


THE  EAR 


521 


tumors  may  be  found,  such  as  fibroma,  lipoma,  angioma,  osteoma  sar 
coma  and  carcmoma;  sebaceous  cysts  are  occasionalh-  preseT     ' 
mdle  £;ar.-  I„fla„unat..ry  overgrowths  and  tumors  are  found  with 

jrro«tl  .  u.th  connectne-tKssue  core  and  epithelial  covering,  gr^  from 
tlw  Kail ;  such  a  growth  is  a  potent  factor  in  the  conti,u.ance  of -m  bflar 
-na  ory  proc-c-ss  that  may  exist.  Fibroma,  angioma,  and  ad  noma  m^y 
'»■  to„„d.     Sarcoma  an.!  carcinoma  are  rare  and  oftenest  secondary 


I'i  i 


CHAPTER    IX 

THE  DIGESTIVE  SYSTEM 
THE  MOUTH 

Abnormalities.-The  most  frequent  and  characteristic  abnormal 
encom.tered  are  harelip,  cleft  palate,  defects  in  the  nnn.her.  arra 
n' )nt,  and  growth  of  the  teeth,  and  abnormal  shortness  of  the  fre. 
of  the  tongue  (tongue  tie). 

„  ^r?'.r^.  Cleft  Palate.-  It  will  be  remembered  that  in  the  deve 
raent  of  the  fiice  the  intermaxillary  processes  of  the  first  visceral  , 
project  into  the  processus  interKlobulares  and  undergoing  fusion  in 
middle  line,  are  separatee!  on  either  side  by  a  cleft  from  the  lat 
frontal  processes,  winch  give  rise  to  the  lateral  facial  parts-this  c 
running  rom  the  month  to  the  orbit.  Later  by  the  development 
the  nasal  passages  the  upper  portion  r,f  this  cleft  becomes  divi, 
into  an  orbital  and  a  nasa  portion.  The  former  becomes  closed 
a  relatively  early  date,  the  latter  remains  open  for  a  somewhat  Ion 
period  as  a  cleft  ot  communication  between  the  roof  of  the  mouth  b 

encount'e    T'^'  "^  I '"'  '"'"•    ^^''^""^''»  ^^^^^^^  development 

m.r       r   ^\T ''''';   *'^"'''   '"""""'  g'-«''^«   °f  malformation,   eitl 
urnlateral  or  bilateral. 

nd'i  ^«^?«°*tl»«P'<»0P0Schisis    persistence   of  primary   lateral   fac 
cielt.     I  his,  the  extreme  condition,  is  rare. 

oJn.!?*"ri'**f  ."'  ^^'  '''^'"'"^  «Ii'velopment  of  the  nasal  passag 
verv  rire  "      "    ''^■^•■'opmnit  of  the  intermaxillary  (arrhincephaly), 

4*  EJ^JI^'f^^tJoPalatoschiais,  cleft  of  lip,  jaw,  and  palate,  unilater 

f  J;,;  '^*?'f  1^"; '''^*  "^  '■''  ''"^  J^^'  ^^''"t^''-«l'  the  intermaxilla 

forming  an  isolated  median  projection;  rare 

ry    CheUoschisis,  l-arelip.     This  is  the  slightest  grade  affecting  wh 
s  the  last  portion  ot  the  clett  to  undergo  closure;  is  most  often  ui 
a  era    and  on  the  left;  the  more  pronounced  form  has  associat. 
(unilateral)  cleft  palate. 

D(^ects  of  the  Teeth.-Xxnong  these  may  be  noted:  lack  of  devel.., 
ment  of  one  or  more  wisdom  teeth,  irregular  position  of  teeth,  persis 
enc-e  of  mi.k  teeth  with  coincident  presence  of  milk  and  permann 
teeth  Lack  of  development  of  the  jaws  to  the  full  size  leads  to  abno 
mal  closeness  of  the  teeth.  S.)me  recent  writers  ascribe  the  increas, 
irregularity  of  jjosition  and  protrusion  of  the  front  teeth  to  the  empl.- 
incnt  of  infant  comforters'-tlummy  rubber  teats  sucked  for  ho.i. 
at  a  time. 


THE   XfulTi: 


523 


iteral   facial 


Hutclmuons  toeth  ,s  a  condition  affecting  the  upper  central  [in- 
.  .s..rs  of  the  primary  set.  These  are  stumpy,  of  ig  shape,  with  a 
.on..avity  of  the  cuttmg  edge;  they  are  frequently  ridged  and  di^ 
color.-.  Hutchinson  regarded  them  as  a  sign  of  congenital  syphH L 
wMe  hey  occur  m  true  congenital  syphilis,  it  is  debatable  Xthe; 
tl.,v  are  no  also  a  paras-  '.c  development  (see  p.  57).  Nor 
ur.'  they  wholly  pathognon  .eing  met  with  also  in  rickets. 

Defe^  of  the   Teeth.-l    ,       tie   is   not   uncommon,  leading  to 
.lela>  ed  speech ;  it  ,s  remediabh  .y  a  simple  surgical  operation.     A  rare 
naltormatK)n  of  the  tongue  is  macroglossia.  or  large  size  of  the  organ 
i-rou^^ht  about  by  congenital  .)bstn.ction  of  the  lymphatics.         ^ 

Circulatory  Disturbances.-While  not  infrequent  and  easily  recog- 
nzahle,  these  call  or  httle  special  note,  save  as  a  reminder  thaTthe 
appearance  of  the  hpsand  gums  affords  valuable  indicatio.,s  of  general 
anemia  or  hyperemia.  '^'"t 

Inflammation.-According  to  the  part  specially  affected  we  sneak 
ISr^tt  ^.'""T-^f'T  "f  the  mouth).  Cheilitis  (of  The  Z\^- 
pvitu  (ot  the  jaws),  and  glossitis  (of  the  tongue).  Considering  how^e 
mou  h  IS  exposed  to  infection  and  traumt  ii  is  remarkabfe  on  the 
on.  haml  how  relatively  rare  are  serious  inflammations  of  this  region 
n  oth.T  words  the  protective  mechanisms  are  here  highly  developed 
U  oun.ls  of  the  mouth  heal  in  general  with  extraordinary  mpi.Syfi 
.l<..s  not  mean  that  inflammations  of  various  orders  are  not  met  with- 
-J.    l.e  contrary.    Some  of  them,  too,  are  characteristic  and  Iservbg 

notice     More  particularly  it  would  seem  that  the  mouth  is  marked"? 

flu..nced  by  disurbances  affecting  the  other  portions  of  .he  drges^ve 

espiratory  tracts.     Here  may  be  mentioned  the  herpes  fabui^ 

tt  frequently  accompanies  lobar  pneumonia,  and  the  ca^rhaf  gW 
■t  s  acc..mpanying  intestinal  infection.    As  a  class  general  infections 

i.l.-t  an  associated  inflammation  of  the  buccal  mucosa,  and  the  con 
'  -..  ot  the  tongue  an.    lips,  varying  as  they  are  apt  to  lin  theTf. 

■   i  kS^S™  •  ""'''"''i^  ?  ^  ^■'^'""^'^  ^'*^«""^*'*^  ^^^-    We  would 
II  Kopbks  s  gn m  measles  (the  appearance  of  punctate  hvperem.V 
^io  >  ot  p„,h,-ad  size,  often  with  a  paler  bluish  centre  on  th^  murv 
-I-  cheeks  and  hps      These  may  bepresent  hours  or  days  before   k 

■  -I'.p.nent  ot  the  sk  n  rash);  the  strawberry  tongue  of  sSfe  er 

to  intense  congestion  and  swelling  of  the  papL  with  loss  o   the 
M"  !.-lunn  over  them);  the  catarrhal  exudate  upon  the  tongue   lios 

■  ;;  ..n„,s  of  the  typhoid  patient,  which  accompan  ed  by  e^'reme 
Ir  ;c>s  of  the  mouth  leads  to  the  production  of  sordes.  dry  dirtv 
"  -,  superficial  deposits.    Cases  are  on  record  of  a  ves  culi'  stoS^ 

""  <^  n^embing  ,n  its  characters  those  of  the  highly  infectious  "ftSt 
■•;.;  n.,uth  disease"  of  cattle  and  brought  about  by  i  Eg  the  mUk 

,,     ,  „j  •'^••'^-tef!,  a  Vesicular  and  later  ulcerative  eruption  may  be 

'  "iKT  characteristic  forms  of  inflammation  of  tiie  nu.uth  are: 


ri24 


THE  DifiKsrnK  system 


mi 


Hii 


Thruah.-  This  is  a  form  of  sproadiiif;  iiu'inhriuious  stomatitis,  be| 
iiing  on  the  toiiKiU'  and  imic-osa  of  the  cheeks,  foumi  in  infants  i 
greatly  (lebilitat(<l  adults,  following  it  would  seem  the  acid  fermei 
tion  of  milk  and  starchy  foods,  and  caused  hy  the  sniH-rficial  groi 
of  a  fungus,  the  Oidinm  tilhinnis.  Beginning  on  the  surface  of 
ei)ithelium  the  fungus  may  extend  into  the  deeper  structures. 

Stomatitis.— Aphthous  stomatitis  is  characterized  hy  the  formatior 
aphthsB,  yellowi>li-white,  thin,  rounded  plaques  sianding  out  against 
reddened  mucosa  of  the  cheeks,  lips,  tongue  and  bases  of  the  gums  I 
not  on  the  gums  themselves.  These  would  seem  to  l)e  of  the  nat 
of  a  fibrinous  exudate.  This  condition  is  most  common  in  poc 
nourished  children  at  teething  and  after  acute  and  weakening  disea 
(bronchopneumonia,  whooping  cough,  etc.),  but  also  may  occur 
pregnant  women  and  in  men  after  exhausting  disease. 

UlceratiTe  stomatitis  shows  itself  most  characteristically  in  the  ja 
and  around  the  teeth.  The  gums  become  (edematous  and  spon, 
easily  bleeding  and  breaking  down.  With  this  the  teeth  are  apt 
become  loosened.  The  jaw  bone  may  be  exposed  and  undergo  necrc 
and  the  ulcerative  process  become  very  extensive.  The  condit 
is  met  with  in  scurvy,  as  also  after  poisoning  with  phosphorus,  If 
and  copper.  With  phosi)horus  the  liability  to  necrosis  of  the  jaw  b( 
is  very  pronounced. 

Noma  or  gangrenous  stomatitis  is  a  very  acute  and  fatal  conditi 
beginning  usually  on  the  cheek  and  rapidly  sprea<lir.g,  with  intei 
congestion  and  oedematous  swelling  of  the  affected  parts,  and  rai 
necrosis.  With  rare  exceptions  it  affects  poorly  nourished  and  vrei 
ened  children.  The  rapid  gangrene  is  very  striking  and  suggests  soi 
specific  agent,  but  that  there  is  such  has  not  yet  been  <letermin( 
Several  workers  have  encountered  the  "bucillus"  fusiformis  with 
accompanying  spirochete.  Others  have  encountered  the  diphthe 
bacillus.  Suppurative  stomatitis  with  the  development  of  nbscess^ 
more  particularly  in  the  substance  of  the  tongue,  is  comparatively  ra 
Among  the  more  chronic  conditions  are  to  be  noted : 
Le'.koplakia.-  Leukoplakia  is  a  condition  following  chronic  irritatic 
characterized  by  epithelial  overgrowth  and  thickf-ning  and  the  form 
tion  of  plaques  of  a  whitish  appearance  on  the  tongue  and  muco 
membrane  of  the  cheeks.  '•■  !;ere  is  here  superficial  cornification  of  t 
thickened  epithelium.  Ti.,  condition  is  seen  in  smokers,  alcoholi 
and  not  infrequently  in  thv  affected  with  syphilis,  and  may  be 
extensive  as  to  give  rise  to  tlie  geographical  tongue.  There  is  a  distin 
tendency  in  these  cases  to  the  formation  of  intractable  fissures  and  sic 
ulceration,  which  may  pass  oii  to  the  development  of  epithelioma. 

Syphilis.— Syphilitic  lesions  of  the  mouth  are  relatively  commo 
more  frequent  than  tubercular.  They  may  be  (1)  primary,  the  chanc 
appearing  on  the  lips  or  on  the  tip  of  the  tongue;  (2)  secondar 
as  an  erythema,  diffuse  or  in  circumscribed  patches  leading  mo 
particularly  on   the  lips  to  fissures  and  erosions.     Mucous  plaqui 


m 


wm 


THE  XfOCTtt 


525 


iiia.\  apptar  diiriiiK  the  socoiidury  stage  or  later  in  the  disease. 
TIk  s.'  may  he  present  on  the  lips,  cheeks,  palate,  and  elsewhere.  At 
fir.t  there  is  a  warty  or  eondyloniatous  thickening.  This  tends  to 
l)nak  down,  leaving  shallow  ulcers  which  heal,  leaving  considerable 
xarring;  (:i)  (ummas,  the  characteristic  tertiary  manifestation.  These 
show  themselves  in  the  substance  of  the  tongue  and  on  the  gums. 

Tuberculosia.— Tuberculosis  of  the  mouth  is  rarely  primary,  and  its 
>tat  is  the  tongue,  and  here  most  fre<iuently  laterally;  along  the  edge, 
tlie  tubercles  tend  to  break  down,  leaving  ulcers  with  thickened  and 
swollen  edges,  not  so  hard  to  the  feel  as  those  of  carcinomatous  ulcers. 

Actinomycosis. — Actinomycosis  in  man,  from  our  experience,  starts 
most  frt(iuently  in  the  cheek,  though  cases  are  found  in  which,  as  in 
cattle,  the  growths  begin  in  the  gums  and  exteinl  into  the  bone.  Leprous 
nv/dules  may  show  themselves  beneath  the  mucosa  of  the  mouth. 

The  tiiree  chronic  conditions  most  liable  to  be  confuse<l  in  connection 
with  the  mouth,  and  more  particularly  the  tongue,  are  tuberculous 
iilirrs,  tertiary  syphilitic  ulcers  and  epithelioma. 

Progressive  Changes.— We  have  already  referred  to  leukoplakia, 
a  .(.ii.litioii  of  overgrowth  and  thickening  of  the  squamous  epithelium 
coNcring  the  tongue.  Of  the  tumors  proper,  the  connective-tissue 
yronj)  (fibroma,  lipoma,  myxoma)  is  occasionally  encountered.  The 
ti nil  epulis  is  employed  for  rounded  tumors  of  benign  tvpe  project- 
iii-  from  the  gums.  The  term  thus  includes  fibroma  and  Kiant-ceUed 
myeloma  (or  sarcoma).  Rarely  do  these  take  on  very  malignant  prop- 
trtits.  The  mouth  is  lined  by  squamous  epithelium,  and  thus  the 
t>  pi(  al  epithelial  tumor  from  this  region  is  the  epithelioma,  or  squamous 
't ll.d  cancer  (p.  209).  Such  epithelioma  may  affect  the  lips  and  the 
toii-ne,  more  rarely  the  gums.  The  characteristics  of  these  epithelial 
tiiiiiors  are  the  formation  of  well-marked  cell  nests,  with  extensive 
sM|)(  rficiai  ulceration  and  the  relatively  rapid  involvement  of  the  lymph 
ikhIcs  at  the  base  of  the  tongue  and  in  the  neck. 

Kpithelioma  may  also  arise  from  the  upper  portion  of  the  pharvnx 
i'lMl  occasionally  from  the  lower  portion  above  the  larvngeal  opening, 
111  which  ('ase  the  epithelial  origin  is  from  the  sinus  pyriformis.  This 
toriii  IS  difficult  to  distinguish  from  primary  cancer  of  the  larynx. 
Kaiiliiiann  lays  down  that  while  laryngeal  cancer  is  for  long  unaccom- 
li'inic.l  by  any  secondary  growths  in  the  cervical  lymph  nodes,  pharj'n- 
^'cal  ( aiicer  is  apt  to  be  accompanied  by  a  relativeh  ormous  infiltra- 
tion ot  these  nodes. 

Teratomas  are  occasionally  encountered  growing  from  the  pharynx 
epignathus,  p.  Go),  or  from  the  palate.  Occasionallv  within  \he 
t'li-iic  substance  posteriorly  may  be  cysts  developed  from' the  primitive 
tiiv  n,i;  ,,ssal  (l„ct  or  from  an  aberrant  process  of  the  same,  the  so-called 
ix'clMlalek  s  glands."  These  cysts  may  be  lined  bv  a  ciliated  epi- 
tiic  -ii.n.  Other  eysts  may  occur  in  the  ducts  of  the  salivary  and 
•'"I  "MS  glands  through  obstruction  and  retention  of  their  secretion. 
1 II   M,-called  ranula  occurs  in  the  neighborhood  of  the  frenulum,  and  is 


■^<C»«.rc4U' 


526 


THE  DIGEST  I VK  SYSTEM 


said  to  be  line  to  a  cUIatation  of  the  diut  of  one  of  the  Blaiiilin-N 
mucous  glaiKls  in  this  noiKhf)orh(K)d. 

Nearly  every  form  of  benign  tumor  has  In-en  (Kcasionallv  desoril 

in  connection  with  the  soft   palate,  pharynx,  and  t„n>ils:   flbroo 

chondromM,  UpomM,  angiomas,  and.  its  alrea<iv  noted,  teratomai  (ei 

nathus,  p.  (i.'i)       The  most  common  growth,  and  that  most  of 

api)earinR  m  children,  is  the  nasopharyngeal  polvp.    These  tum 

are  of  the  same  order  as  the  nasal   polyps  already  described 

IS  worthy  of  note  that  the  latter  may  frequently  'project  into  i 

upi)er  pharynx.    Of  the  malignant  tumors,  large  and  round-eel 

sjircoma  of  the  tonsils  and  pharynx  are  occasionally  encounter 

hpithehoma  may  also  originate  over  the  tonsils,  and  is  peculiarly  t 

to  lead  to  extensive  ulceration,  with  erosion,  and  liable  to  cause  de.i 

from  involvement  of  the  carotid.    It  is  distinguishable  from  a  chan. 

of  the  same  region  by  its  undermined  edges  and  more  nodular  floor 

As  might  be  exjiected  from  the  abundance  of  lymphoid  tissue 

the  pharynx,  the  various  orders  of  lymphosarcomatous  growth  b 

encountered  m  this  region.    Thus  in  leukemia  there  may  l>e  overgrow 

of  both  the  tonsils  and  the  general  submucous  tissue  of  the  pharvr 

Very  similar  overgrowth  may  be  encountered  in  the  preleukemic 

aleukemic  conditions,  while,  further,  lymphosarcoma  may  show  its, 

primarily  in  the  tonsils,  and  then  is  apt  to  be  rapidly  infilt-atir 

.Such  growths  are  very  vascular,  easily  break  down,  and  lead  to  gangr.  i 

and  liemorrhage. 


THE  TEETH 

A  few  words  should  liere  be  given  regarding  diseased  conditions  ( 
the  teeth  which  the  ordinary  medical  man  is  apt  to  neglect,  althoue 
we  are  coming  to  realize  that  they  are  of  material  influence  upon  th 
general  health.  ' 

Caries.— Caries  is  the  commonest  of  these  disturbances.  Tli 
I)rocess  is  due  to  a  progressive  decalcification  and  destruction  of  tli 
substance  of  the  tooth.  It  is  brought  about  by  the  agency  of  micr. 
organisms  which,  producing  acids,  dissolve  out  the  calcium  salts.  Thes 
bacteria  gain  entrance  through  erosions  of  the  enamel  and  grow  alon 
the  canals  of  the  dentine.  While  this  is  the  case,  it  has  to  be  recognize, 
that  the  tooth  is  not  wholly  inert  matter,  and  that  its  power  of  resist 
ance  to  this  microbic  invasion  varies  greatly.  French  writers,  mor 
particularly  of  late,  have  called  attention  to  the  fact  that  during  preg 
nancy,  and  in  the  early  stage  of  tuberculosis,  there  is  a  distinct  lower 
ing  of  the  general  calcium  content  of  the  organism  and  coincidently  ; 
marked  liability  for  the  rapid  supervention  of  dental  caries. 

Pulpitis.— Simple  caries  is  unassociated  with  pain,  but  where  it  i; 
present  microorganisms  have  penetrated  along  the  dentine  canals  v. 
the  pulp  and  there  set  up  an  acute  inflammation  that  is  intensely  pair: 
ful.     Ihe  exudate  may  be  of  suppurative  type  and  so  form  an  absct  -, 


THE  TEETH 


527 


(IrstroyiriK  the  pulp  atui  extending  to  the  root  of  the  tooth  and  so  to 
thf  alveolus,  inducing  aii  alveolar  periostitis;  or  again  the  pulp  cavity 
remaining  closed,  the  abscess  may  niaki-  its  way  (I)  through  the  hone 
of  .ither  jaw,  usually  on  the  outer  aspect,  and  here  either  discharge 
Its."  f  or  undergo  absorption;  or  (2)  abscess  of  the  upper  jaw,  notably 
of  the  cannie  teeth,  may  extend  upward  and  set  up  acute  inflammation 
(if  the  antrum  of  Ilighniore. 

Pyorrhe*  AlveoUria.-Tiiis  is  a  form  of  I(»w  suppurative  alveolar 
|..ri„stitis,  origniatnig,  it  would  seem,  not  from  the  root  of  the  tooth 
l)iit  at  the  angle  between  the  gums  and  the  teeth  and  graduallv  working 
.Imvnward.  loosemng  and  lea.ling  to  the  falling  out  of  tooth  after  tooth 
'li.e  condition  is  in  general  painless,  and  apt  to  escape  notice,  save  on 
.Namination.  This  condition  has  come  in  for  increase<l  recognition  of 
late  years  owing  to  the  teaching  of  Hunter  and  others.  It  is  held  that 
the  constant  discharge  of  the  infected  pus  and  the  swallowing  of  the 
same  leads  to  a  low  and  continue.!  form  of  gastric  inflammation  which, 
111  Its  turn,  IS  responsible  for  the  supervention  of  grave  anemia.  To 
Mil)l)nrative  conditions  in  association  with  the  teeth  have  also  been 
as  rilKjl  the  occasional  development  of  aspiration  pneumonia,  gangrene 
nt  tlie  lungs,  and  chronic  swelling  of  the  lymph  nwles  in  children. 

>ikIi  pyorrhea  is  said  to  be  often  preceded  by  tartar  of  the  tMth 
1  his  IS  a  very  common  affection  and  easily  set  up  if  the  mouth  be  not 
wa>he,l  out  after  meals.  Portions  of  food,  cell  debris,  etc.,  collecting 
in  the  angle  between  the  tooth  and  the  gum  become  the  seat  of  growth 
'•t  hptothrix  and  other  bacterial  forms,  and,  as  noted  on  page  315 
•iileanous  salts  are  apt  to  be  deposited  in  the  broken-down  materiaj 
>..  that  a  calcified  layer  of  extraneous  matter  coats  the  lower  part  of 
f  le  tooth.  If  left,  as  the  epithelial  scales  are  given  off  from  the  surface 
"I  the  Kuin  and  are  prevented  from  being  swept  awav  by  the  calcified 
""Her  above,  these  dead  cells  in  their  turn  become  the  seat  of  a  cal- 
••..'.oMs  deposit,  and  so  the  tartar  appears  gradually  to  push  its  way 
'Inn  Mward  sei)arating  the  tooth  from  the  gum. 

Tumors  of  the  Teeth.-The  development  of  the  tooth  as  a  differ- 
'  HtiMte.l  portion  of  the  epithelium  of  the  jaw  is  a  complicated  j)rocess 
.<Nd  li.mc  quite  a  series  of  tumors  may  develop  from  one  or  other  por- 
i"n.  ihese  tumors  may  he  either  solid  or  cystic.  Of  the  former, 
tMw  may  be  localized  overgr.wth  of  the  enamel,  adamantinoma,  exces- 
^'y  loeah/ed  .levelopment  of  the  dentine,  odontoma,  of  the  cement 
iiiwtance,  dental  hyperostoses,  while  from  the  root  of  the  tooth  there 
'||='>  he  either  connective  tissue  or  epithelial  growths.  Kaufmann 
|"Y'ies  tiie  cystic  overgrowths  which  may  be  found  in  the  jaw  as 

".  Tooth  cysts. 
Ii.  Root  cysts. 

(!)  Simple, 

(2)  The  periosteal  cysts  of  the  jaw. 
''•  -Multilocular  cystomas. 


i2S 


T'lh:  i)!f,h:sri\  t:  systk.m 


Thf  -iimplc  tiM.tli  eyits  ori>{irint»-  from  noriiiiil  <>;•  anr  sorv  touth  s 
or  niispliu-»'<l  |M>rtioiis  of  sucl)  k.tiiis.  Tli.s,-  cists,  lii fd  hv  an  v\ 
limn,  nro  most  ofton  iiiiilociilnr,  l>iit  ma\  Ir-  multilocular,  aixi  tluv 
••oiitaii!  r(i<iiint>rits  of  tt-rth. 

Root  cysts  arc  the  result  (»f  periostitis  of  the  nM>t. 

Tht  miiltiloci'Iar  cysts  are  thin  walUil,  cansitig  absorption  ot  the 
of  the  jaw  with  ^reat  swelling  of  the  same. 


u 


i^ 


hi 


SAUVART  GLANDS. 

Inflammation.  -  The  most  important  (ondition  i':  associii 
with  the  salivary  Klaiuls  is  angina  ludovici  (eynanche).  This 
very  acute  inflammation  <.f  the  floor  of  the  mo'ntii  and  of  the  u 
portion  of  the  neck,  which  is  supposed  hy  many  authorities  to  c)rif,'i 
from  the  suhmaxillary  fjland.  It  is  a  rapidly  extending  infiltra! 
the  surroundiii);  tissues  tending  to  suppuration  :ind  i.'anRrene,  an 
IS  liable  to  end  in  a  general  baoteriemia  or  fatal  (ed(  i.ia  of  the  glo 
Mumpa  or  epidemic  parotitis  is  a  highly  infection^  condition  chara( 
ized  by  pronounced  enlargement  of  (me  or  both  parotid  glands 
aecomi)anied  by  a  mrolerate  grade  of  fever  and  general  disturba 
That  the  infection  is  not  merely  local  and  confined  to  the  paroti 
shown  by  the  frequent  coincident  orchitis  in  the  male  and  by  an  inH 
ruation  of  the  ovaries  or  mamma'  in  the  feni,  > .  The  disease  n 
particularly  affects  the  male  sex  before  the  age  u  'wenty,  and  the 
parotid  is  apt  to  be  more  involved  than  the  right. 

Tuberculosis  and  other  specific  inflammations  of  the  salivary  gla 
are  relatively  rare.  Concrements  (sialoliths  forming  in  the  di 
of  the  salivary  glands  are  occasionally  encountered.  These  re: 
from  catarrh  with  obstruction. 

Progressive  Changes.—Tumors,  more  particularly  of  the  parotid,  fc 
a  complicated  series  of  growths,  nor  can  it  be  said  that  the  exact  relati 
ship  of  the  series  has  been  fully  established.  Occasionally  we  encoui 
pure  adenomas  and  j)ure  adenocarcinomas;  more  frequently  then 
an  admixture  of  cell  groups  of  very  different  types,  what  appear 
be  epithelial  elements  intermixed  with  fibrous,  cartilaginous,  or  m 
actively  .sarcomatous  developments.  As  a  rule,  these  mi  \ed  tumors  gr 
slowly,  and  while  they  arc  apt  to  spread  locally,  despite  their  maligiii 
appearance  they  show  little  tendency  to  recur  upoi.  removal.  M 
particularly  li.ese  tumors  are  apt  to  show  cells  of  the  connective-tis: 
type,  or  sarcomatous,  in  definite  relationship  to  the  vessels  of  the  py 
the  so-called  i)erivascular  endotheliomas  or  peritheliomas  (p.  I'^l'). 
where  the  outer  mas.ses  of  cells  undergo  hyaline  degeneration  (cyl 
dromas  (p.  28.S).  It  is  often  difficult  to  come  "to  a  determination  wh.  rl 
the  alveolar  masses  of  cells  of  these  mixed  tumors  are  of  cpitii.I 
or  endotheiiai  origin.  We  are  inclined  to  state  that  no  satisfact' 
or  generall\-  accepted  explanation  has  been  afforded  for  the  frequen 


mm 


mmims&::im.  w^m' 


77/A    (KSOI'H.UilS 


r..'9 


(.f  ih.-o  niixt.l  Krowths  of  th     |mrti«'iilar  n-^'um.    Tumors  of  thr  same 
orl.r.  thoupli  rare.  Iiavt-  l><       (Ij-mtIIkhI  in  uss.K-iation  with  iIh>  sub- 

in;i\illary  ^'laml. 


on  oi  the  bone 


THE   OBSOPHAGUS 

.\otwitl,>tan«nn>;  its  ex|M.s«^l  <-on<lition  its  liability  to  infwtion  from 
f.MMl  Mil. stances  mikI  .lisiharKes  ^vvaiio\M-.l  from  ihe  month,  its  liability 
iilx.  to  traumatism  from  the  foo...  atrections  of  this  orpin  are  relatively 
iiiin.inmon.  In  other  words  tin-  lininjr  s<|namons  epitheliuni  is  en<lowe(l 
with  .onsi.lerable  resisting  power-.  \Vh,.n  it  is  involve.!  in  dl-rase 
the  (Meets  upon  nntriti(.n  an-  very  serious,  hence  sneh  .lis(.niers  of 
tlie  o  ...pha^rus  as  show  themselves  are  of  very  «-onsi.lerabl.-  clinieal 
iiii|M>rtaiiee. 

Hen  eertain  anatomical  data  may  be  recalled.  Averaging  L»."  em. 
or  10  inches  in  ieuKth  in  the  adult,  the  (esophageal  tube  is  pressed  ii|M)n 
a  httir  1.1  low  Its  origin  b\  the  cricoid  cartilage,  then  s  em.  below  its 
(in-iii  l.y  the  left  bronchus  which  crosses  it,  and  shortiv  before  its 
ttrimiiMiion  m  the  stomach  it  passes  through  and  is  apt  to  be"  compressed 
li>   the  diaphragm.     It  is  at  these  |M)ints  ol   relative  narrowing  that 

irritant  matter  taken  with  the  f I  is  apt  to  suffer  relative  arrest  and 

tli.M',  therefore,  are  the  sites  of  election  for  morbid  .states.     In  the 

Mi'lMT  portion  the  muscle  is  striated,  in  its  lower  plain  ami  involuntary. 

A«  throughout  the  «ligestive  tract  this  muscle  is  arranged  in  an  outer 

"iidiiiid  and  inner  circular  layer.    There  is  also  a  well-developed 

nil  ■1.  iris  miicosie    The  mucosa  is  formed  of  a  s(iuamous  epithelium 

*'M  ,  .     asional  mucous  glands.     It,  some  J,')  per  cent,  of  normal  indi- 

!.ii-i>  small  islands  of  cyliidrii  j-celled  epithelium  are  encountered 

ii|«per  half  of  the  a»s. ),-.;; it ;.'!!-     {)„  section,  these  eloselv  resemble 

tli<  -a-tric  mi  cosa,  and  lu^    ■  be     regarded  as  such  by  simie  a'nthorities. 

Nhndde  has  pointed  out,  however,  that  the  originally  cvlinder-celled 

t|iithriiimi  of  the  foregut  gives  rise  to  various  orders  of  epithelium, 

iiiiil  il :  t  III  these  islands  it  has  proceeded  to  develop  into  a  cvlinder- 

"II'       'Mdification  rather  than  mto  a  sipiamousHclled;  these  "are  not 

;m~i      riji-n'sts  in  the  proi)er  sense  of  the  term. 

Malformations.— These  are  uncommon.  There  mav  he  complete 
absence  agenesia)  or  in  part  the  tube  may  be  representwl  by  a  fibrous 
'"r.l  the  ,,-ran  thus  forming  a  bliml  sac.  Oceasionallv  there  is 
'"""'•'meat  with  the  trachea.  Partial  or  complete  duplication  has 
'•' !  r,  ,,,r(l,.d,  I,  dized  narrowing  or  stenosis,  and  the  presence  of  a 
i"l"  ■  i  diaphra;,  i,  causing  occlusion.  It  must  be  remembered  that 
till  r,  i.iratory  system  originates  as  a  <liverticulum  fr«)m  the  primitive 
'T'^ii!,  and  occasi(mally  we  encounter  cysts  in  the  upper  thor.j\ 
l.\in-  Ih  tu(-en  the  (esophagus  and  the  trachea,  lined  by  ciliated  -pithe- 
•'"'i'  ^  -'Vc  find  isolated  accessory  masses  of  lung  tissue  immediately 
"""^'  !lM.  diaphragm.  These  must  be  regarded  as  originating  from 
iuc-   ,,■>  respiratory  diverticula. 


530 


THE  DIGEiiTlVE  SYSTEM 


■I 


!:! 


Acquired  Malformations.— Occasionally  in  hysterical  individuals  and 
nervous  states  contracture  of  a  portion  of  the  oesophagus  is  brought 
about  by  muscular  spasm.  Whether  from  such  continued  spasm,  or 
trom  acquired  stenosis  (by  pressure  from  without,  by  new  growth  in 
the  wall,  or  by  cicatricial  contraction  after  an  inflammatorv  process), 
the  portion  above  the  site  of  narrowing  undergoes  dilatat'ion.  This 
dilatation  is  sometimes  enormous.  Idiopathic  dilatation  has  also  bren 
observed.  A  similar  condition  has  been  produced  experimentally  in  the 
dog  by  cutting  both  cervical  vagi. 

In  addition  to  this  generalized  dilatation  we  recognize  also  local 
dilatations  or  diverticula.  These  are  of  two  orders,  the  so-called 
pressure  and  traction  diverticula.  The  latter  are  not  uncommon,  their 
usual  site  being  on  the  anterior  wall  just  below  the  bifurcation  of  the 
trachea.  They  are  dearly  associated  with  tubervulosis  and  other 
inflammatory  disturbances  of  the  group  of  lymph  nodes  situated  in  the 
angle  between  the  two  bronchi.  As  a  result  of  this  inflammation  the 
tissue  around  the  nodes  is  involved  and  fibrous  bands  or  adhesions 
are  developed  between  the  nodes  and  the  a'sophageal  wall.  As  a 
result  with  each  peristaltic  act,  in  swallowing,  the  oesophagus  is  pulled 
upon  at  this  point  and  gradually  a  small  expansion  or  saccule  becomes 
developed. 

Tlu-  pressure  diverticula  are  rarer.     These  occur  at  or  in  the  neigh- 
borhood ..t  the  middle  line  on  the  posterior  aspect  of  the  oesophagus 
close  to  Its  origui.    At  this  jioini  the  muscle  wall  is  at  its  weakest.   The 
usual  teaching  is  that  through  the  pressure  of  a  large  bolus  of  food  the 
mucous  coat  becomes  pressed  outward  through  a  defect  in  the  muscle 
wall  and  soon  a  small  amount  of  the  ingested  food  or  fluid  collects 
in  the  lower  portion  of  such  an  expansion,  so  that  with  the  successive 
acts  ot  swallowing  the  divcrticnlum  gives  way  more  and  more;  more 
and   niorc  foodstutt'  c(.llects  in  the  lower  portion  of  the  saccule  thus 
tormed,  until  gradually  from  the  weight  of  this  food  and  the  irritation 
and  weakening  of  the  wall  of  the  sac  prcKluced  bv  the  same,  there  is 
developed  an  clongat.'d,  blind  sac,  (  vtending  downward  on  one  or  other 
side  in  front  of  the  vertebnd  column,  it  may  be  for  .-everal  inches  and 
even  into  the  thorax.     Isually  no  muscle  fibres  are  found  in  the  walls 
of  this  sac. 

In  this  connection  we  may  iioic  rertain  other  acquired  conditions. 
Rupture  is  rare.  Perforation  may  occur  from  swallowe«l  bone,  etc.,  IVoin 
eroMon,  from  syphilitic  and  cancerous  ulcers,  at  the  base  of  tri..ti.,n 
diverticula,  by  i)rcssiire  of  retained  foreign  bodies,  or  by  extension  of 
inflammatory  conditions  from  without  (caseous  tuberculous  glands, 
aneurysm,  etc.). 

Post  mortem  st.ftcning  and  riii)turc  may  be  brought  about  h\  the 
action  of  the  acid  gastric  juice.  This  may  occur  where  there  is  rela- 
tively sufidcn  death,  with  full  digestion.  \ery  rarelv  mav  this  dig(  stion 
occur  intra  vitam,  with  the  production  of  ulcers  at  the  lower  end  of  the 
oesophagus  of  the  same  ord.r  as  the  i)e|)tic  ulcers  to  be  describe.!  k.ter. 


Tim  (EmriiAars 


531 


Circul.tory  l»mrbu,c...-Of  these  the  ii,a,t  iiote«„rthv  an,  the 
tr,.;.tly  .hstended  v.r,c,,«  submueou,  vein,  of  the  lo."    eS-emTtv  J 
tl„.  ,.rsan,  y„  ,„  eonditi™,  of  obstruction  of  the  poLdrcSon 
ml,  ,,  x.e,.ll,v,  ,„  ca«.s  of  portal  eirrhosis  of  the  li%cr     Thev™^  Ze 

-;.»iv,.  pharynge^rdiSrSlTixl'    inXnX  Xi"r«rr  °""' 
.  an.ls.  etc.     These  may  lead  in  the  milder  cases  to  an  ISe  dtram 

",^Z"nri,„^'r:-;;S7„"„t?"  -■""■;'••  ■""""  '^- 

Tl,.  f  ^^v  """"iiT'O'';  «)  also  are  aarconiM 

q«tl,,.|i,„i,  of  the  o^r    f^e^      r  """'""""S  '"■"  the  »quam„,  , 

"f  t  '  r  nobt?  ff  ''■^''''  ■"'''  f  *"™"'-  '""•^  d«^-l«P.  namely,  or^ 
^^^•^^^^Zk^:^r:Z^:^y:^7'^  "°^^^:  J^^^  'tatistic/from 
r-Tion  i.  in' Xed  Oifrln^  ^'- ''"'''7  ^''^  ^'^'^^^  o"*-  «r  other 
-  'Ii-    -M..S    c  m  n..„    it.    K  /""P'"''""  '"'■^'■^  *^«  ""'^'"^  region 


(■\t(l!.M., 

then  i 
thcv 
H;it'i, 
llic  V 
thii! 


IPW 


5:i2 


rilH  DlflKSTIVE  SYSTK.Xf 


astinuni  .,r  thoracic  cavity.  Tl.n.iiKh  infiltration  u,,wanl  and  down- 
ward  tlie  growth  may  extend  a  considerable  distance.  Softer  adeno- 
(■arcniomatoiis  growths,  on  tlie  other  hand,  form  lar^e  n.asses  projecting 
into  and  blocking  the  a'sophajjiis.  The  bronchia!  nodes  are  especially 
liable  to  l)e  the  seat  of  s(>condary  growths;  metastases  at  a  distan(-e 
are  relatively  uncommon.  By  direct  infiltration  the  trachea  lungs 
or  vertebra-  may  be  involved.  It  will  be  nnde.-stood  that  through  the 
passage  of  food  over  the  ulcerating  surface,  gangrenous  conditions 
extending  into  the  neighborhood  are  liable  to  supervene 


If. 
}     V 


THE  STOMACH 

The  stomach  is  of  the  nature  of  a  pronoi.n.i  '  dilatation  in  the  course 
of  the  alimentary  tube.  This  tube  in  early  fcrtal  stages  has  a  compar- 
atively direct  course  in  front  of  the  future  vertebral  column,  but,  with 
further  growth,  that  portion  which  is  to  be  the  stomach  both  increas-s 
m  length  so  as  to  ff.rm  a  loop  downward  with  what  is  to  be  the  pvlorie 
end  remaining  relatively  fi.xed,  and  at  the  same  time  undergoes  dis- 
tension and  some  rotation,  so  that  what  had  been  the  posterior  aspect 
comes  to  corresi)ond  with  the  greater  curvature  tuniing  to  the  left  and 
lorward.  J  he  wall  consists  of  three  main  layers.  From  either  side  of 
the  vertebral  column  the  perit.  iieum  i)asses  to  it  to  form  a  mesenterv 
whose  two  layers  separate  to  cover  it  and  join  again  along  the  lowi-r 
asix-ct,  now  forming  the  great  oment  im,  which  passes  down  and  n  'urns 
to  the  vertebral  column,  whence  again  it  is  reflected  over  the  transverse 
colon. 

Beneath  the  serous  coat  is  a  loose  connective  subserosa.     The  muscle 
layers  are  well  developed,  consisting  of  an  outer  longitudinal,  an  inter- 
mediate,   somewhat    illxlcfined    oblique    laver,    originating   from   the 
former,  and  a  circular  layer.     At  the  .listal  end  of  the  stoi  uich  the 
musci-latiire  undergoes  a  marked  increase  so  as  to  form  a  sphinct.r, 
the  pyloric  rmg.     The  mucosa  is  relatively  verv  thick,  consisting  of  ,i 
cyluidri.al-celled  cpithcluim  with  abundant  long,  glandular  invaginn- 
tioiis.      Ihese  glands  form   simple  and  (.ften   in   the  pvlorie  portio- 
forked  tubules,  ditrenng  in  tluir  constitution  in  the  cardiac  and  the 
py One  regions   respecti\cl\ .     The   cardiac   region    mav   present   two 
orders  of  cells,  namely,  the  nior.'  regular  cylindrical  chief  cells.  gi\  iiiij 
origin  to  a  i)epsiii-c()iitaining  secretion,  and  the  angular  or  polvgniKil 
oxyntic  cells,  v.ith  a  more  peripheral  i)osition.  giving  origin  to  the  ;.(i<l 
of  the  gastric  juice.     These  latter  cells  are  wanting  in  the  pxi-rio 
;  ortion  of  the  stomach. 

Between  the  various  gland  tubules  and  again  between  the  inn 
and  the  imiscic  layer  is  a  well-defined  submiicosa.  abuiulantly  va- 
with  occasional  solitary   lymph  nodules.     In  the  resting  orV.mtr: 
state  of  the  stoniacli  the  mucosa  ••xhibits  a  series  of  longitudinal  . 
or  rugie. 


I. -a 
';ir, 
'.'d 
.Ids 


THE  sroMAcn 


533 


As  (leni()nstrate<l  hv  Cannon's  ni..tfir.,l  ^t  a 

hourglass  stomlch      (1  \  "  I  1    ,;''f 'I'^T'^'^^^*^^-^^^^     t»'^^'^  "rclers  of 

'<'Ni,'.iiital  h    )ertr.)nl,v  ,.f  tJ       "'/"    ""  '•"""'""y  there  is  a  state  of 
-'1.1  Ml.er  of      ;  ee    a  Ltl;;.r"f '■''"'•- ■■'  ""'/  ''""t^'xtio..  of  an 

I'^'lf   li  iiiCancv  with  <,.,„>/         T     on^in      J  In-   t„rmer   man  fests 
tl'.'  ^nm,a  u.      1   et  '         I  "^  *-'"^t"'\<'''«trnetion,  .lilatation  of 

^'-.tio„  \.UnZT^["l:^,^'^  ","  ••''^'•"^'""  "•  ''t  antops,-  the  ol>- 

hyperemia  fo  lows  the  r.-i-Pnti,..      /•    •?       '  "'   ^*''*''-     Aetive 

«•;  -  i.  .1..  e^lj  ;;,X";i  r,',,;:'^;;;;;,';:'"  "■•■  *— ^^ 

f-.v.  i„p.„,^.  i,  ,,.„,;,„,,  ,„_.,,,   ,„;,„,,^,^,.  ,  .^^_^,^  .^^ 

ri/l   +*.    ..    1-.. ,  ^ 


Mill 
;iM;. 
;i   I'., 

Vrin 

a  !,,■. 
He 

iiiiili 
til, 


''■-nw  t,\,„.  „f  gastritis,  *'"  ''''^^''''P'^^'nt  ol 

rrhages  arc  w,t  iiifr.  ,„i,.,  t      TIihv  mn,    k      -.i 
"I'linth.  ..riiMs        .;.  '         •    be  either  (1)  minute, 

'"Hum  J,em..rrl,«^^  oozing,  from  v.-ssels  ho  small  as 


534 


THE  DIGESTIVE  SYSTEM 


ii 


to  ,e  invisible  to  the  oye;  or  (H)  solitary,  gross  and  free,  leading  to  great 
sudden  loss  of  blood  and  tending  to  be  rapidly  fatal.     Minute  hemor- 
rhages, ecchymoses.   are  seen   in   many  different  conditions:    (o)  in 
hemophilia,  passive  congestion,  acute  catarrhal  gastritis,  where  there 
has  been  severe  vomiting,  phosphi  r^w  and  arsenic  poisoning,  condi- 
tions, that  IS,  associated  with  dilated  or  degenerated  states  of  the 
capillap-,  or  (6)  they  may  be  the  result  of  a  nervous  or  neurotic 
dilatation  of  capillaries  as  in  hysteria  and  (probably)  the  gastric  hemor- 
rhsiges  of  pregnancy,  or  (c)  th.-y  may  follow  the  erosive  action  of  caustic 
substances  that  have  gained  entrance  in  the  stomach  or  (d)  they  may 
be  secondary  to  multiple  emboli  into  the  gastric  arterioles,  or  throm- 
hosis  of  the  larger  gastric  veins.    The  beginner  must  be  careful  not  to 
confuse  with  these  the  common  condition  of  apparent  hemorrliage 
along  the  gastric  vessels  brought  about  by  post  mortem  digestion, 
and  due  to  diffusn.n  of  hemoglobin  and  changes  occurring  in  the  same. 
1  he  submucous  hemorrhaKe  is  apt  to  induce  necrosis  of  the  immediately 
overlying  mucosa   by    cutting  off   its   nutrition.     While  the  gastric 
juice  can  exert  no  influence  upon  the  living  cells  of  the  mucosa,  dead 
mucosa  is  acted  on  by  it;  there  is  In  fact  no  difference  between  it  and  the 
dead  animal  matter  that  may  bo  introduced  into  the  stomach  as  food. 
It  follows,  tlierefore.  that  the  state  of  multiple  hemorrhages  tends  to 
gi\e  place  to  t;  at  of  multiple  hemorrhagic  erosions.    We  shall  describe 
these  more  fully  under  the  regressive  changes.     We  would  suggest 
tentatively  that  wh.'tluT  there  be  developed  easily  recognizable  sub- 
mucus  hemorrhages  witli  little  evidence  of  erosion,  or  on  the  other 
hand  .iif^use  oozing  with  little  or  no  indication  of  submucous  hemorrhage 
IS  pn.hably  determiiud  by  the  acidity  and  activity  of  the  gastric  juice. 
\\  Jien  this  IS  j)owerful,  so  soon  as  a  small  area  of  the  mucosa  is  of 
<k-presse,|  vitality  through  und.rlying  vascular  disturbance,  it  becomes 
digested  and  removed,  affording  a  minute  ulcer  with  a  bleeding  capillarv 
at  It^  base.  *      ^ 

Gross  luinorrhages  may  l>e  brought  almut  by  the  rupture  of  a  rela- 
tively la  ri;r  vein  inpassive  congestion  (most  often  in  cirrhosis  the  rupture 
attects  not  the  g.istnc  but  the  lower  esophageal  veins).  Common.r 
causes  are  carcinoma  and  round  ulcer.  The  verv  nature  of  the  can- 
cerous growth  determines  that  where  it  infiltrates  the  surface  the  oiit.r- 
niost  layers  are  apt  to  be  poorly  nourished,  to  undergo  necrosis  nnd 
ulceration.  The  digestion,  therefore,  of  the  necrosed  matter  is  apt  lo 
expose  some  ({..p  vessel,  weaken  its  wall  and  favor  hemorrhage,  in 
the  i)eptic  ulcer  there  is  a  similar  process  of  necrosis,  ulceration,  i id 
exposure  of  a  deep  vessel  (see  p.  o.'JG). 

Blood  discharged  into  the  stomach  and  mi.xed  with  gastric  hure 
takes  on  rapidly  a  brownish  coffee-ground  appearance  owing  to  tlie 
action  of  the  acirl  iii)on  its  hemoglobin. 

EmboUsm  and  thrombosis,  as  already  indicated,  may  involv.  the 
gastric  vcsmIs;  we  y^hall  take  up  their  effects  in  di.scuss'ing  the  ]<•  Dtic 
ulcer. 


THE  STOMACH 


535 


Inflammation.- Acute  Oastoitis.-The  historical  studies  of  Beaumont 
.m  lu.  toinach  of  Alexis  St  Martin  have  taught  us  how  easilv  ern^of 
^.tHHluee  inflammatory  changes  i„  the  gastric  nmcosa.  an  o3ose 
.  alcohol  bringing  about  acute  hyperemia  and  even  the  development 
ot  a  vcsicuilar  eruption,  with  discharge  of  greatly  increased  amoSrof 
nnuus.  Acute  catarrhal  gastritis  is  characterized  more  particularly  by 
t  s  pouring  out  of  abundant  mucus  from  the  goblet  cells,  along  lith 
..tlur  inodihcations  in  the  composition  of  the  gastric  juice  notlb  v 
...nnution   of  the    hydrochloric    acid.      The  mucous    membrane  is 

lK!'r.t'.''rrh.d".-lf!"^''  "^^  TY™"^^^"     "-t«Io«i^-«ll.v.  i»  a.l.lidon  to 
tiK-  c.itarrh  il  infiammation  of  the  mucosa,  there  is  a  small-celled  infil 

''■'' of  the  submucosa  with  marked  congestion        ™^"^^"^  """- 

Phlegmonous  Gastritis -This  is  a  rare  and  fatal  condition  character- 
.".1  l.x  the  formation  of  sub:nu<-ous  abscesses  which,  spreading  separate 
iK'  mucosa  from  the  underlying  tissues.     With  its  necrosis  the  pufi; 

;t;    T      '"^."/h^  ^tr^^''  --^"^  ™S«^^  ^^^^-  develop.    Tn  To 
c.    s  the  condition  ,s  of  streptococcal  origin  and  is  one  manifestation 
ot  the  pyemic  state;  in  others  it  is  idiopathic,  unassociated  wi  I  abscess 
o  . nation  elsewhere.    Drunkards  show  some  predisposition  to  this  form 
I.r^umably  as  a  complication  of  subacute  gastritis 

Membranous  Gastritis.-Membranous  gastritis  is  also  rare  apt  to  be 
.■n|o„„tere,l  more  particularly  in  the  newborn  and  young  chSen  in 
«Im.„,.  ,„,|,rd,  true  gastric  diphtheria  has  been  recorded. 

Folhcular  Gastritis.-As  rare  or  rarer  is  follicular  gastritis  with  oro- 

Chronic  Gastntis.--Cl,ronic  gastritis  may  be  broadly  of  two  forms- 
>  ..rrophic  and   (2)  atrophic.    The  first  of  the'se  is  seen  more 

r':;;  ;';e'''.hr''t^'r"^  those  sufl^ring  from  chronic  St^S 
■u    -liMMscs,  although  It  may  result  also  from  any  chronic  irritation 

1 1:  stiuf  dXv'rT'^  ^"'^  ^rv^^-'  rLntbirfood  • 

r.-o.M  i"  h      th    ki  H^       ""'    ^v^■^'n^\  digestion.    The  mucosa  is 

pi'M      'tioo      u  7    u'V!'"^'-;'^  •"'^^'^  "«'"'••  ^^''th  at  times  some 
u  u  ntat.on.  the  result  of  iinperl.ctly  absorbed  hemorrhages.     There 

;  -i  "HH-ous  pnxluct,,.,.  and  discharge,  but  what  is  m'ost  charac- 

-H  .  .  wh  n  t^';;;  'u",;!  t ■  ---V;^'  ^-nukr  appearance  of  the 
«   .n  tiK  mxvn.  has  been  washed  off  or  otherwise  removal 

'-  -  w  h  "lis;;;:  tr  -^.^ y-^-i-ti-t  thickening  of  th/slib. 

'-'■  —  I   i  ns    fxt         h  ;  1^  '"^'V"*?"=  ^«  infiltration  and 

,'      '"'r.^'^**'«l  f^^tween  the  gland  tubules,  which  are  further 

I'"'  1  -.n   s  .f  sill       ^°'»'^*^'-\J?'-f""a^  appearance  is  <hie  to  closelv 
'  ''■  '     n ore    V    if.;   '''''^'''^'^''  ^^b  of  gland  tissue  and  stroma.    ' 

.  Im     .  ,,  'l        r.?'?  ^Tv  P'""'  '"  ""'^''^  '"  "'^'^^  the  mucous 

l»^Posa     uLl'        "'^  •)■  *'*''-^'.*'"  "■  P«Pi""»'atous  form,  gastritis 

q.Hstionable,  but  m  some  cases  in  which  it  is  found  there 


530 


THE  DIGEST IV K  SYSTEM 


in 


w 


is  definite  history  of  such,  in  others  the  polypoi.l  masses  appear  to  ori^ 
.nate  from  the  e.I«es  o    h.-ale.!  nh-ers.     It  is  possible  tha    I  prop^,      fr 
ot  rases  represent  a  l,lnst..n,atoi,i  <-.,n.htion-a  ten.lenev.  Ihat  is 
iliHuse  papillomatous  overgrowth  upon  minimal  irritation 

Atrophic   gastritis   .nay   he  the   outeome  of  a  fihn.i.l    hvpertrophif 
Kastnfs;  the  atrophy  of  the  «lan,lnlar  elements,  that  is.  m«ri  e 

Iw       In  r        r^'^y  *'»'  ""''-'.vi"«  overgrowth  of  ...nmeeti 
tissue.      In  a  ecmsi.lerahle  pn.portion  of  <,,ses  there  is  no  verv  nro- 
np»Mce.l  suhmueous  hhrosis,  hut  hoth   nuuosa   an.!   suhmueo^a  a  e 
I  nun.shecl.     It  „,ay.  nalee.l.  he  questione.i  whether  they  woul.l  ,  otl" 
Letter  pla.-«    anmn^  the  regressive  clisonlers  than  among  the  inflam- 
".ations.      M.eroseopieally  the  ^astrie  ,.|an.ls  are  grea  fv     h,   t^^ 
w.th  large  lumen  an.l  eells  relatively  shrunken.     The  eon  lit  <m  i^  , 
mfnjcp^ntly  fV.un.l  asso..iate.l  with  pernieious  anemia  .l^d   m;.;LS 

Specific  Infections.     Of  the  specifie  infections  tuberculosis  is  rare  an.l 
never  pnmary.     Syphilis  is  also  rare  though  ulc-erations  ar.  oeeaTo„a 

m  I>ar.  to  the  existence  ot  suhacute  or  chronic  gastritis.  Gastric 
actmomycosis  an.l  glanders  have  heen  re..,r.l...l.  n.-eration  of  the  ra  e 
sohtao-   Mph   f..lli..|..s  .,f  the  stomach   is  one  of  tlJa.;- .^iLr:^ 

Regressive  Changes.-  Of  .legeneration  pn.per  there  is  little  that 
calls  for  furth.-r  note,  save  that  calcareous  deposits  have  been  descrM 

hange^  that  may  .,n„lv.«  the  mucosa  an.l  the  various  ulcerative  pr..- 

there  uZ  '.!  P'''*;P""";".^f  ^tnt.s  w..  have  alr.-a.ly  inlliiated  that 
m.st,™  -'Krrati.m  ot  ,nflammat.,ry  .,rigin  in  the  st.miach:  the 
'K  "'"■••s  ^■.K'o.int.Te.l  inthis.>rgan  are  non-inflammat..rv. 

lift  ;  ;'  ;V  ''"'  7  ""  "■''"'"  "'•r''*'^^'"!''''  ^"xaminati..n  the  e<lges  show 
K^Tr  r'n  •V""T"""  r"',"'*'^'  '"•  ""  «"'»ll<-^'lled  infiltration. 
Iv  s  b. ,  7  "^  *'•"'  "^"'i"  ^':.  ^  "'  ''"^'^'•'*'""  "'"'  ^^'™"^«"  °f  an  «rea  th.t 
I  e  m.  t.ple  small  an.l  (2.  the  s.,litary  or  few  large,  the  latter  consti- 
le  W.n  '  'JT''  "^r-  ^  ''•'  "'■''"''■"■•^  ^'-^t-'">"k  take«  little  note  ,.f 
c,nr  f  i'-nn  '':  •'•'  ''"""'''tt™!  no  less  than  six  examples  in  the 
e  t      ^•^'l";;'"*'^ ^>7  f'K^-tl'*'-  with  others  that  appear  to  he  the 

fi?i„  ;  ^'L!  '  '"•■^•^''•>P",V't.  In  this  form  there  are  foun.l  from 
Jn^Tr  *^''^V''■  "^'"•^'  ^"'""  '"•'■"^  <>«•  l'»^s  .,f  tissue  of  irregular  sluipe 
and  from  1  to  o  mm.  across,  most  often  in  the  middle  zone  of  the  or,nn. 
I  nt  at  times  m..re  ,n  the  canlia.-.  at  .,th,-rs  more  in  the  pvloric  n-io„. 
lhe>  have  pale,  ch-an-cut  clg.-s  an.l  in  gcu-ral  a  sm....th  base  forine.1 
of  t  le  subn.uc.sa  ..r  at  most  th.-  muscularis.  Their  abun.la.ur  ami 
small  size  gne  the  lining  ..f  the  organ  a  .l..ci.le.lly  moth-eaten  ap|..ar- 
ance  \ery  rarely  do  they  p.-rforate.  In  n.me  of  the  cas.-s  nn,  we 
recall  that  there  were  any  sympt..ms  calling  attention  to  st..niach 


THE  STOMACH 


537 


Iroiililc 


iio    li'  inatciiK'sis,    no    rncU'iin      Tli«»-   k ...     i  .       . 

;:"  :^,:i'r;.r;;;:;:'Si  XrB:  ^^"^-^^ 

("r «,.  i,„v,.  i„  Sr    „ii.r  r     ^™ 

'•"ll-..unes.  Dps.  INk^     Jv    /i  1.1    ^  its   activity.     Ijeoently  onr 
ot  ui,l,.<,.r,..   I        •11  •        '''"'^t^'  ""ve  (lemonstratiH    ri  one  ras.. 

;i:S:';;;i;;  :Se  Sc^ '  rn  :5t- ''"''""■  r"  *"-* »'- -'^ 

■n;;.  l;.st..an  in'tlu-'t^H^^K  Im.cor "  °"  '''  ^"^^"^  "^'"^  -'^• 
-St^";;;tSi,r h'"""'^  'T''  "''^'- »'-  t'-  '^'"-•n«  char. 

'li«  rr  .nay  I,,-  two  or  tl.R-e  nrose n  •  it  ^     »      '.  u^*?'  '''''*"^''  '^"^ 

^""'11.  is.  if  w,.  niav  s    exnr^^^^^^^^^^  '^"'^r'  ""*  «'"'  ^■''^" 

>|..MHk  tl.at  if  V    h  t    .  •  r l     Tr't  •I"'-""".  ^"'•^-      ^^^  ^'^^""t  corre- 


""i"^'  to  tlu-  hr-t  tV.„f      -.1    :.    •  ."I  tne  ulcors  fail  to  perforate  fn 
i^'Ha^m    t  o^i"       'f,  ^^"'H'  *'".'"""«  -f  the  stomach  wall,  adhesive 

I. r,.;,     1       ',;;',    .^  '^'\  i'P   •'•t^-^:^'"  the  base  of  the  ,.Ic;r  and  the 

■-I  l-f .;;;.''     ;;:;'f '•"'"''«  \'-"«-     I»  this  case  the  digest  o^ 
'•>"  --toratio.tm.^'^'r"" '■**'•:  "«>;'"^V  the  a.lherent  organ. 


llM 

Tl 
til 


'  ''oration  is  m.wt  ....^  *     "" ^  "'".  """  """  »<»"t"rent  organ. 

'■"  •'  ^'"""'  ^'''■''^-:^^  t"  !»H.  cause  of  this  form  of  ulcer  there 


'"  i»lMn.(iant  hvnn   ."    •  ^"\''»"«e  ot  this  form  of  ulcer  there 

i"''"-ciou    area  tiL        ;        r'"^'  '^"y'^^t'  ^^'^^  **  --rresponds 
■    irt.Tics      \n       I  •    ««i'!iision  ot  a  branch  of  .*ne  of  the 


m 


:)38 


THE  niGKSTIVK  SYSTEM 


w 


iv»  Y 


often  in  individuals,  man  nn.l  won.an.  wl„.  sh.m  n<.  sij;ns  of  enilmlism 
elsewhere      For  th.s  reason  othvrs  hnu-  suKKest,,!  a  local  sLstic  ,.»? 

htr  u  7'"-''""' -t--.-''  y-t  <'thei::seein;tlr;hr'Si^:; 

LTT      •..'■"'"'"*  '"  ^'''  ""''  '""^'  "^  the  stornach.  ocrlnsion  71 

the  museulans  winch  occurs  after  nu-als.  The  solitary  nature  of  the^ 
ulcers  ,s  opposed  to  causation  by  irritants-hot  fo-nls.  etc.-  acting  from 
w  th.„  the  stomach ;  such  shoul.l  set  up  nn.ltiple  lesions.     XeSi  " 

iLf'n'  rl\  T  '^"«"  '"••>■  ix-'xii'"'"!  the  like  order  of  ulcer«  in  the 

first  part  of  the  .luodenum  l.y  liKaturins  the  common  bile  duct     Such 
hpature  does  away  largely  with  the  '•alkaline  tide"  in  this  rein  a" 
favors  thus  the  deleterious  eHe<-ts  of  the  aciditv  of  the  eh  me      Now 
IS  to  be  noted  that  there  is  a  close  associati<,n  between  ^ric  hpe 
act.v.ty  ar..l    he  deveh.p.nent  of  these  jK-pti,  ulcers,     wt  are  inc  ined 
to  lay  down    he  tollo^^i„K  as  essential  factors  in  the  proceL 
o    'vu-        "'"'''^ '    »t'<Totic  or  necrescent  nnicosa. 

of  the  irmi'lnrbrnf'  ^""7'""''  '\''^'  '^^  »r'''^  "^  distribution  of  one 
ot  the  terminal  bran  ncs  of  a  gastric  artery  in  which  either  primarily 
o  secondan  V-  there  ,s  arrested  circulation-primarilv  through  em boie 
.other  oeclus.on  of  the  artery,  secon.lariiy  'through  stasis  and  tW 
botic  change  niduccd  cither  by  some  local  irritant  or  it  Zv  bp  l 
t  e  actu>n  of  the  hyperacid  gastric.  Juice  acting  ..n  a  s^lbmlripriVe^ 

j,ciMric  juice  l)y  mtlammation. 

(3)  A  normal,  or,  preferably-,  hyperacid  gastric  juice 
It  may  be  aske<l  why  a  generali/ed  inflammation  of  the  gastric 
mucosa  is  not  followed  by  extensive  peptic  ulceration      Th.   a™ 
.s  that  generahzed  inflammation  leads  constantly  to  the  ,  rodmZ 
of  a  gastric  juice  of  ,|imi„isl,c.!  activity  an.l  digestive  power     Fo     h" 
production  of  peptic  ulcers  the  trastrie  mu.osa  in  general  must  be  mL  .1 
.    not  producing  a  juice  of  hvi.^htened  <ligestive  capadVv  and  wS,  Ti  is 
there  nn.st  be  some  local  tocus  of  lowered  vitality         ''''*'"'*  ^''^'  **"' 

the  srcr'^ff'\"'*l'  ."17"''"  "''""^'^"  ""*""*'"»  '"«•■  be  directed  to 
Thu  'A  s  .  !ft  r  "V''  r''t  ^'^"^tic  agents  t.pon  the  stomach  wall, 
an  soft  n  .  ;  f  t  ■'  '  '"  ''  pronounced  gelatinous  or  slimv  swellin, 
an  e  w^fh  ^  .  !'i  'TT'"'  ,  ■^"'"''""''  ""''  *"  ''  ^^'y  '*'«thery  appear- 
n  rL  ^c  1*^1'  "  ''  .l.scolorati.>ns.  According  to  its  concentrrtiou 
i  .  „  J  ^  ''  ''u''  -^'""'V'''  ''"'"'"^'  "^  ^  •^•^*""«'i«h  brown.  ( '.r- 
.  i  n  ZL"-"'"'  ^'"'"^  'r'"'"""^'  "^""*'  «^''''  Kreyish-white  disclor- 
eoDneV^.  r?  ^"'^''"'"t^^'-  "  f''-'  '^^-white  superficial  precipitati..;,, 
copper  sulphate  a  greenish  discoloration 

tro^hT'"'"*  Changes.-  \Ve  have  already  -vferred  to  simple  hyp<  r- 

mS\  r"'f  '■''T^'  '""'•'''•''  *'"^  larger  proportion,  of  so-ca!K,l 
p  oric  hypertrophy  of  later  life  are  not  true  hypertrophies,  are  n<^ 
tliat  IS,  example's  of  overgrowth  of  the  main  tissue,  in  this  case  of  ti.e 


THE  STOMACH 


639 


P.vlori,-  musclar  rinR.  b„t  are  ,lue  to  fibrc.i.I  hyperplasia  either  nf 
Of  bemjjii  Krowthg,  siihnnicous  and  subserous  flhmn...  u i 

■■»r.mo„,a  I,.,  it,  ™£  '  "  "  '™""  ™*  "■»«  ">''  '<"-  of 

"•  •!'.    .HdervU  tis  ul^s    Z  "  '"T"^'"*  i-jfiltration  and  invasion 

.n.-.  p-r';;?rSr:::^,x^Ssr^heS^-^^^  -« 
'2Ti,r^  ^''""'T'^  ^f  ^  size)  of^h^t^r  .^:yi;;f 

""'■       wkl   lar«    Ska"  r  ""r."  ^''.^  "^'^"""^  «"«•"'  -t'undantiv 
Simplex;  f      cSus  cLe^^^t^^^^^^^^^  *?,  ^"■^S^^^'  ^^^  «*^^^^-<"n« 

«i'l^  litti,.  emlen^rfnT      !,''*"'''''''  S'flall cells, abundnnt  stron.a 
V      u.       ,    -        ^'^^*''  ''"''"'  «'"^**'' '«««  "'deration,  although 
>     aM>  .ievelops,  and  great  tendency  to  infiltrate.    The  cau^  ' 

"     ot    glauir  *    I  ?n-*  'f'^'"''  ^--  type  and  le.; 
"    oi    glandular    relationship,    lumen    formatmn     *.*«     ti  • 

-s   orin  IS  niost  cmmon  in  tfe  pylori^  regSittginnlng  often 

' '       ,    hP?T'  ""'  "^*""^'"g  '"*"  the  duc^enum  butS 
^  -li  the  ualls  of  the  stomach  from  the  pyloric  toward  the  cai^diac 


will 
tlii 

rW 
ill.; 
sii; 
a  >■■ 


o-H) 


Tin:  DiaESTivK  system 


r':-  ! 


in.l,,;i   tl ,.      i  ,    "„    ""Nm'H.i  i-sLhs,,,,,  tl,n„n.|,  tl„,  rtoiimch  wall; 

as  only  t..  !„•  .li.s,.ov..n..    I,v  .an     itUl      tI  '"'"'"' "^ 
sec.ii.larv  irn.wtlis  is  in  t  ".      .         '™'-.    ^'""  """'""'""'^t  site  for 
curvature   next       tl ..  "  "     '  ,'  ""t"'  "*""**'*'  ''"t'^"'^'  *»'«  l^-^^r 

J  he  m.,st  strikmK  <li,nVal  feature  aeeompanvinR  gastrie  caneer  is 

sZl      l'."""'"'  "'  '■"'■  "■'■'  '■"  ^''"  ^^-naeheonte?;        '"""'  " 

eve"    "la    """"■•'  ?"■*■"""  "^  ''•^'  ^*""""''  '^  "  "»«'h  l-s  fr«,ue,.t 

f.-w  e  S  in  wLeU  r  t'"   '""'"r"*:''.  ^V'^*'-  «"'l  we  have  seen  a 
ni  \vln.h  ,t  has  l,een  .nv,.lve.l  in  Kniphosareomatosis. 

THE  INTESTINES 

I      su.m.Kt,  ,,>  tile  most  inij..,rtant  seeti..n  of  the  digestive  traet   Lut 
s  >      fo    I , '  ' ;  '  '■  ■  '/'^  '*"""^''  '•'"'"'""*^''  ""•'  'li««o<-iatingthe  m...  . 

CO      i"t?  e    ;\        .•T''"''"*''''-  '"-'^  '''"^■^'  ^'••""  the  stomach,  in.l-  ..I. 
ex-  See      T  '      V'"*'""'  ''  ^''''^''"^>'  ^-"'Patible  with  e<,ntinM,i 

•Mst.nti.     Jiu.  „,.n.  absorption    of   foodstuffs   occurs  in  the  <..u.ll 


THK  isrKsrtsKs 


Ml 


•-  "•  (-2)  tlH.  .mil  latwto.       u      1  "'•  "•'"'""'•  '^■^""-  it  P«^«'« 

"1  <li'-  f.«.,l.  pr„tn„s.  c.rholn.lnt.  s  ;  n   T  ♦  "?""  ^■••"^t't"»-nt.s 

i.-i.nilal,U.;  (.{)  tho  l„,rito.«B.  J        ^'f  "rv  r.-n.ler..,|  s„lul,|e  „n,l 

i-pi -u.  the  .nn,;iii3rcS  ,,f  t:i  ;;;i"';"  ''^  r  ^'"^  '""■"  *" 

7  inort  urtne  npion  of  absorption;  t\w  greater 

Fia.  230 
^RANSV.COL. 


ILIAC 
COLON 


llllii 
iiriil 

pnr, 

•I  I' 

II      llM 

To  , 

pirt, 

vjiri ! 


''""'•l"'.t  !^.^tmaI  Hon,     f  th  'T'  '"'  P-^t^'^'*""'  against 

i'  ".liv.  .olo,,    „      .,.,;„   ^ '      "^'^'*-  "•  •'^^""'  "I-  has  its  divisions 

'    vi.nv  we<.a,,Mot   ,Je   ^  ?!    '      ,'*'  ^''"'^  '"""^i""  "'  «i=^»"- 

-'  '"-pp.- .,;:;,  r"Si.:''"^^  ^'"^  ^'"'  ^*"'»-h  - » 


''^'Ircstatic  relations  iin>;nf/K     '  ""^  '«' impress,.. 


.«ve  JWi^  <«n~j«; 


MICROCOPY    RESOLUTION   TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No   2) 


1.0 


I.I 


1.25 


•IT  IS 
1:  1^ 


2.5 
2.2 


2.0 


1.8 


^  .APPLIED  IM/1GE     Inc 

g^  16^3    Las*    Mail    Sl-eel 

F.^  Rochester.   Ue*>   vort        1*609       USA 

'^S  (716)    *82   -   OiOO  -   Phone 

BSg  ("6)  288  -  "^gsg  -  fai- 


wm 


"IT 


542 


77/ A'  mCESTIVE  SYSTEM 


m  -i 


.ill 


in  the  ascending  colon  undergo  inspissation  prior  to  discharge  jier 
annm.  In  other  words,  the'  cecum  and  ascencHng  coh)n  have  physio- 
logically to  undergo  great  variation  in  the  volume  of  their  contents. 
It  would  be  to  the  oetriment  of  their  function  were  they  to  be  acutely 
susceptible  to  pressure  changes,  were  they  to  undergo'peristalsis  and 
void  their  contents  immediately  they  became  filled  from  the  ileum.  We 
must  regard  them  thus  as,  in  the  normal  state,  distinctly  unresponsive 
to  pressure  eflects.  It  is  the  appendix,  we  hold,  that  is  the  hydrostatic 
agent  initialling  peristalsis  in  the  large  gut.  In  it  we  have  a  narrow 
tube,  \yith  no  such  pronounced  ^•a^iations  in  caliber,  so  situated  that 
the  weight  of  the  column  of  forming  feces  is  communicated  to  it,  and 
we  presume  that  when  this  weight  reaches  a  certain  point,  the  distend- 
ing force  acting  upon  its  walls  originates  muscular  contractions  wiiich 
sj)read  directly  into  the  cecum  and  so  initiate  the  forward  movement 
of  their  contents.  Such  a  view  explains  the  tendency  to  constipation 
in  the  bedridden,  in  whom  this  gravitational  influent^  of  the  contents 
of  the  ascending  colon  can  have  little  effect;  it  explains  the  normal 
tendency  to  empty  the  bowels,  either  shortly  after  rising  and  assuming 
the  erect  position  or  after  the  first  meal  when  stimulating  peristalsis  of 
the  small  bowel  has  driven  extra  contents  into  the  cecum  and  so  in- 
creased the  load;  it  explains  the  constipation  that  follows  some  interval 
removals  of  the  appendix. 

At  the  other  end  of  the  colon  we  have  another  hydrostatic  mechan- 
ism. In  normal  health  the  rectum  is  empty  until  immediately  preceding 
the  act  of  defecation.  As  Hertz  has  shown  that  act  is  brought  about  by 
the  sensitiveness  of  the  preanal  portion  of  the  rectum  to  internal  press- 
ure, but  this  sensory  mechanism  becomes  soon  exhausted  if  the  pressure 
continues,  if,  that  is,  the  call  to  defecate  be  not  attended  to.  Once, 
therefore,  the  rectum  is  loaded  and  not  duly  emptied  it  is  apt  to  become 
overloaded.  This  rectal  constipation  with  all  its  attendant  ills  and 
miseries  is  guarded  against  by  the  siphon  action  of  the  sigmoid  flexure. 
The  formed  fecal  matter  does  not  gradually  dribble  into  the  rectum; 
it  gradually  accumulates  in  the  descending  colon  and  the  proxininl 
lim!)  of  the  flexure  until  a  column  is  formed  of  sufficient  length  to  set 
up  the  pressure  necessary  to  surmount  the  curve  and  once  aroun<l  the 
curve  the  whole  column  sijjhons  rapidly  into  the  rectum.  Once  there 
it  exerts  sudden  pressure  upon  the  anal  region  and  demands  diseharp\ 

Constipation.-  It  will  be  seen  that  constipation  may  be  of  varic  ns 
orders:  (1)  obstructive,  from  kinks,  contractures,  etc.,  of  one  or  otln  r 
portion  of  the  gut,  arresting  the  inflow  of  the  contents.  (2)  Fecal 
inadequacy,  when  either  from  starvation  or  from  the  ingestion  of  eii-'!y 
absorbable  or  predigested  foods,  sufiieient  indigestible  remnants  .nc 
not  afforded  to  possess  by  their  volume  a  hydrostatic  effect.  In  m'  Ii 
cases  haniened  feces  accumulate  more  particularly  in  the  cecimi  '  il 
sigmoid.  (.'{)  Atonic,  when  either  (n)  the  sensory  limb  of  the  r-  x 
are  is  exhausted  or  depressed  and  pressure  within  the  gut  doe«  (t 
excite  peristalsis   as  in   rectal  constipation  or  (6)  through  pre      is 


THE  IXTESriXES 


543 


.listcnsion  or  disease  the  musculature  fails  to  respond      (4)  ADDendi«*I 

Ihese  watery  feces  may  be  of  various  orders  and  due  to- 

>orf  pending  excessiv,.  pmstalsis.    He™  »e  mav  d™l  w,th  a  reSex 
*t  up  by  ainiormal  TOntnils  r,f  the  bowel  nr  hv  „,fll,  Ji 

■.•n.«ry  „i„„,la„.,  „.  ,6)  ,he  int^ind  «  a,„'^  C  be  unt" 

"    tome  ID  consist  of  little  beyond  serous  f^u  d  with  shreds  of 

- i»H,v  a.,:ctT:,Ti„,''„ih<!'£e;"  """"""■■  -^''"^  ""«■«- 

„r'll'"l".'l''' ."",''  of  Mcrctions  from  the  bowels  it  deserves  here  to  h. 

:;i^r,?^S^;r.S'Z':,-;;nS-,?^5S 

■runic  stati,  uhich  lead  to  necrosis  and  ulceration  of  the  colon. 


'rf; 


r,  hard  (t.  e.,  difficult),  i^up,,,-,  the  bowel. 


-r 


544 


THE  DIGESTIVE  SYSTEM 


Hm'iitiv,  Hiss  has  (lomonstrated  (■(.ticlnsively  that  bacteria  are  (lis 
charged  trom  the  circuhitioii  into  various  portions  of  the  cut,  and  thi 
after  ligature  of  the  common  bile  duct. 

AbnormaUties.- Apart  from  considerable  va-'-itions  in  length   thi 
most  common  abnormality  is  the  presence  of  i..9ckel's  diverticiiluin 
or  the  persistent  remams  of  the  proximal  part   .f  the  omphalomeserai. 
duct.     Ihere  m<»y  be  various  grades  of  the  persistence  from  the  com 
plete  duct  openmg  at  the  navel  (very  rare),  through  the  state  in  whicl 
a  hbrous  band  adherent  at  the  navel  represent:;  the  distal  i)ortion  an. 
passes  into  a  diverticulum  opening  off  the  ileum  and  lined  with  mucosa 
representing  the  proximal  portion.    The  most  frequent  condition  is  a 
hnger-hkefreediverticu  am.one  to  threeinches  in  length,  with  orwithout 
a  mesentery  of  its  own,  given  off  from  the  ileum  from  thirty  to  fortv 
inches  above  the  ileocecal  valve.     We  have  encountered  this  in  '>'? 
per  cent   of  our  autopsies.     Belonging  to  the  same  svstem  are  occa- 
sional abdominal  cysts  representing  a  persistent  intermediate  part  of 
the  duct,  and  the  condition  of  persistence  of  a  congested  moist  columnar 
epithelium  upon  the  navel,  or  it  may  be  an  actual  blind  sinus  leadinr 
down  froiP     ,c-  same.     More  particularly  where  there  is  a  fibrous  band 
of  attachnu.it,  the  diverticulum  may  become  the  cause  of  internal 
hernias  with  strangulation  of  coils  of  the  intestine.     We  shall  refer 
later  to  the  acquired  diverticula. 

The  api)endix  in  addition  to  variation  in  length  mav  be  abnormally 
placet!,  and  infrequently  retroperitoneal. 

Another  important  condition  of  congenital  origin  is  congenital  hvpcr- 
trophy  of  the  sigmoid  and  often  of  the  colon-megacolon  (Hirsch- 
sprung's disease).  In  this  there  is  noted  in  the  young  child  a  progressive 
enlargement  of  the  abdomen  until  it  attains  huge  size,  and  associated 
with  this  there  is  progressive  constipation. 

On  oi)ening  the  abdomen  the  sigmoid  is  found  of  relativelv  enormous 
size,  occupying  the  greater  part  of  the  cavity.     There  mav  or  mav  not 
be  associated  enlargement  of  the  descending  c.Jon,  or  "the  colon  in 
general,  and  with  this  pronounced  hypertrophv  of  the  coats.    There  lias 
been  much  discussion  as  to  the  causation.     In  two  well-marked  cases 
seen  by  us  there  was  an  abnormal  mesentery  of  the  sigmoid;  the  lower 
end  ol  the  descending  colon  was  closely  bound  down  bv  the  peritoneal 
attachments,  and  gave  ;.lace  to  a  large,  fan-like  ineseilterv  of  the  sig- 
moid proper,  with  similar  binding  down  of  the  sigmoid-rectiim  junction, 
a  condition   favorable  to  obstruction   by  kinking  when  the  sigmoid 
becanie  loaded  and  so  to  its  progressive  distension.     One  of  the  tuo 
cases  had  a  similar  close  binding  down  at  the  splenic  flexure  with  corre- 
sponding dilatation  and  hypertrophy  of  the  transverse  colon.    Oth.rs, 
liowever,  deny  the  e\  idence  of  this  primary  and  anattmiical  (lil\<-t, 
and  p(.ssibly  there  exists  another  order  of  eases  in  which  not  potential 
obstruction  but  primary  atony  of  the  walls  is  at  fault. 

The  third  important  group  of  abnormalities  is  that  of  the  stenoses 
and  atresias.    The  presence  of  membranous  septa  occluding  the  diio- 


rt '  ! 


THE  IXTESTIXES  545 

of  the  omphalomL:  aic  due  e  rr'";^''"'  '".  *''^  '•^*^'""  "^  ^'^'t 
stenoses  that  can  on  ^be  ex  hined  nlT  "f;'"''  contractures  and 
|H-rit.,nitis.     The  most  freauen   sir  •'  "^t" /'^^«»'t«  "^  antenatal 

onhrs  of  atresia^^  a  nra^^il;;*  f  ?''' ''  ^'""^t't^t^d  by  the  various 
tlie  doacal  septu^and  tolack  J^irnrr;?'"''" '  *"  P''^^^'^^^^  o! 
apposition  with  this.  "^""^  "^  *^^  "^^*"'"  *"  ^"me  into 

tlu':.:J::l^raSof7^^^^^^^^^  "J^-^  -e^"' *«  pass  rapidly  in  review 

Two  orde  s  of  acqu  ^ed  ^iS;'  °™  j*"^,  P"-^'!'""  "^  the  intestines. 

tivo;  (2)  paralytic'  The  J^rmt^shows  Lelf  af*  "  ™""'=  ^'-^  °*"*^"^- 
str-Ktion  whether  by  stenosis   I.-nl^n      it.elf  above  any  repon  of  ob- 

"><.tter  and.  if  orgenerlrde^ilc^;^"^  ^f '  •  "'"'^  ^l"  ''"'^'^*'""  ^^  ^^^^^^ 
tlu-  latter  is  seen  ^^erito;^t^  f  '  '^^«^.""«t«^  ^^ith  hypertrophy; 
■""nia.  etc.);  it  is  evidSv  the  r!"i"7l'  •"^'^.*'""^  ^*>Phoid,  pneu^ 
"Pon  the  musculat.>re  of  the  bo^eh        "^  '"'  "'""  '^  ^^^*^"«'  *-'"« 

tl..'  .Rifrhhorhood  of  the  amo*!,^  ^7^""'".  «"'•  there  particularly  in 
i'nsn.t  themselves  at  theTpJ  ^*''"'  '"  *'^'"  •'*"^«"  '"testine  hev 
-'«"-Iy.  where  the  bllsS"l/T*^^*   ""'^'^"*'^-^  "^  *'^^  ^^'j- 

t'"'.  "innlar  muscle  :n:r;,,^:i„"Sdrtren;'  '^"r'*"*;  ^-''.""^'^ 
'•"-ircle  thcKut.  Thev  thuscnn«tl^.  u  '  *V  ^T"*^^^  *^'^'"Jes  to 
t.ric  attachment;  the'"  ma"   be  muU  ni     Z  themselves  at  the mesen- 

"f  tlu.  colon.     Thev  ocTur   n  the  wf  I  "'•''  '•""'''"'  ^'^  diverticula 

tl'f  longitudinal  nnusc  e  and  and  mav  r'""'  "itermediate  between 
"'■  tl"-  nature  of  small   hernias  of  T         "'"^  numerous.     They  are 

,  I,,  fibres  have  HttL  Z  i^"?  """""'^  ''*^tween   the  circular 

^'f  tl...  sero  ::  ¥1  ev  occu  wheTlf  '1  *''t  7''''  ^"*  ^"  -*"  -^t 
•■"Hs  of  c-hronic  crstinTn„  .  f '"^'P'  ''^  *'"'  '""^^'e  i«  favored,  in 
tlK'  suhscrunat  te  *  ?II  'k"  ""  '  ^"^^  "-^P"'  disappearance  of 
'"■'•'"•.(.  the  sea?  ofr^r  .-'"''T'  ^'^^J^encl.  Occasionally  these 
-ll^linHilraJht       "'«^""«*»«"  (diverticulitis)  with  excessive  smaT 

eitl°l^lc  1.;;;* sL^!7  ''  --^  'T  "^  '"*^^*"-  "P-  -tself  mav  affect 
t" tn:,.;irp Teir^^^  •"*^^*"--     It  '-''-^  naturallv 

-■^u:  bvTsr^nL'r  '"'J^'*  ^''•""*'  '-^-^^'^y  —•  -ther 
-"--ns  a,u    l™f„    he^e?..^^^^^^^^^^^^^  "  hernial  sac.  or  between 

■'>"  thrse  rases  the  Z2erL^Z  ''^'''^'''  '''  ^>  invagination.    In 

'''•■■''-'•"rsaprogrrs  fvelv  nZr  ^"'"P^^^^'^^  before  the  arteries  and 

st.^f'r'l^.^^i'^J^*^^^^  is   brought  about   bv  irregular  peri         ' 

^;.       n,ore  accurately,  .ncoordinat.on  between  the  contractions 


5  in 


THE  DIGESTIVE  SYSTEM 


:ri . 


tii-...^.- 


of  the  longitudinal  and  circular  muscles,  whereby  a  part  of  the  e 

above  IS  either  projected  into  the  segment  immediately  below  or 

caught  by  that  lower  segment  in  its  contraction.    As  k  result    on 

caught  within,  the  peristaltic  contraction  propels  it  downward  iu«t 

If  It  were  a  fecal  mass  within  the  lumen.     In  this  way  long  segmer 

of  the  bowel  may  become  invaginated  within  the  portion  of  bow 

below  and  may  indeed  appear  at  and  be  projected  through  the  ami 

It  will  be  realized  that  the  attached  mesentery  likewise  becomes  invagii 

ated,  with  compression  of  its  vessels,  congestion  and  liability  to  gan 

rene.     Inflammatory  adhesions  are  apt  to  form  at  tli.   reactive  upp; 

end  of  the  invagination  and  thus  the  gangrenous  intussusception  mav  n 

off  without  there  being  escape  of  feces  at  the  line  of  junction      In 'sue 

cases  a  zone  of  stenosis  in  the  shortened  bowel  mav  he  the  outcome  ( 

the  process.     In  other  cases,  unless  operated  upon,  the  obstruction  an 

to.xemia  may  lead  to  death,  or  there  may  be  peritonitis  from  perforatioi 

Ihese  invaginations  may  involve  the  ileum   done  (ileal),  or,  at  th 

valve,  the  ileum  may  become  invaginated  into  die  cecum  (ileocecal)  i 

which  case  the  cecum  and  appendix  may  also  be  carried  forward' t 

form  part  of  the  intussusception;  may  be  colic,  affecting  the  colon  alont 

or  colicorecta  ,  the  colon  becoming  invaginated  within  the  rectum 

^    Ihis  irregular  peristalsis  occurs  most  often  in  young  children,  an( 

in  them  therefore  invagination  is  most  frenuentiv  encountered     As  i 

curiosity  we  may  encounter  one  invaginatioi,  setting  up  a  second  invag 

mation  below,  and  so  presenting  not  three  but  five  coats;  or,  again 

through  reverse  peristalsis  the  invagination  may  occur  in  an  upwarr 

direction.  ' 

Such  reverse  invagination  is  most  frequently  seen  in  the  conditior 
of  agonal  invagination.  Often  at  autopsies,  more  particularly  upon 
children,  small  invaginations  of  the  small  intestine  present  themselves, 
evidently  due  to  irregular  peristalsis  during  the  death  agony  or  in  the 
hour  or  two  immediately  succeeding  death.  They  differ  from  the  other 
cases  111  their  tendency  to  be  multiple  (three  or  more),  in  their  small 
size,  in  the  absence  of  any  signs  of  inflammation  of  the  serosa,  and  in  the 
ease  with  which  they  can  be  reduced. 

Circulatory  Disturbances.— The  great  vascularity  of  the  intestinal 
mucosa  renders  it  apt  to  roact  in  a  very  pronounced  manner  to  altered 
circulatory  states;  it  shows  extreme  pallor  in  cases  of  general  anemia, 
intense  acute  hyraremia  in  inflammatory  states,  and  even  more  marked 
engorgement  and  purplish  coloration  in  conditions  of  passive  livpcr- 
emia,  such  as  follow  partial  or  complete  obstruction  of  the  p.irtal 
vein  or  its  mesenteric  l)ranclies,  or  obstructive  cardiac  disease.  In  this 
passive  congestion  the  subserous  veins  stand  out  prominenth  ;  the 
muco.sa  assumes  a  bluish-purple  color,  is  swollen  and  succulent  through 
cedematous  transudi-tion,  and,  as  already  noted  in  connection  witli  the 
stomach,  if  the  condition  is  of  some  duration  there  are  evidenc.-^  of  a 
secondary  and  accoi..panying  low  inflammatorv  state. 


THE  INTESTINES  547 

"Irralion    (typhoid.     d3ier  ™°f  ™"'7.  ">«lie"Mt  growths, 

.»n„B  to  .lissoc-iation  of  the  hemoXbin  .^7   •■    bowel  becomes  tarry 
li<.lr.«...,  of  the  feee,.    ThereTav  ti-f       .""  ^'  ^'Ph-WW 

tf  ■»  «Mher  from  the'tSch  „t'  S  "." ICh  b*  °'  """" 

iiiiKcale*  hv  the  natural  fnl,>r,,f+i,    t         ""*""^^'  ^"icn  becomes  so 
>..v  -lelicate  Uo^.^'^^S'l^^^gt^^^^r  *^  '^  — ^--ble.  save 

^^^ST:f^,^'^:^^      -tensive  serial  anastomosis  of  the 

tion  where  an  important  Cnch  of  S^  1  'T  <^o\\&teT^\  drcula- 
""  ''"'"'lus  or  otherv^se  obliter«  L"*'''i  ^"^^'^  ^^^"•"^^  blocked  by 
infant  f,,rmation.     Si    ir^ou^^^^^^^^^  *  '"^"'t'  ^^^^'^  ^^y  be 

than  i„  the  large  gut     tL  rSfvS- 

inches  and  more  according  tf^K  •  ™'  '"  ^t*^"*  f"""™  ""e  to  fortv 
•—  bloS^r  ex'S-d"^^^^^^^^^  *h%«^«^>-  that  his 

the  intestine.     It  varies  ?n«l  '  *^^  "^'^tance  of  the  lesion  from 

oftin.thatelapt\TrelXnre?  Tl^^  W"^'  ^^^''^  ^^^^'th 
inijjth  „f  gut  seen  from  without  is  of  a  hin.^i'  ^f  ^^  f  tages  the  affected 
presents  an  intensely  crgSed  thtS  ^'^'^T'^''''*'*"^  «"«P«"i"S 
I^ater  tlu-  superficial  layers  mav  h^        t  ?^  hemorrhagic  mucosa 

'''-•'•'l-staine<l  matte  /and  EtiUtTwhr^r  t^''  ^'^'^  ««^'"«  «f 
mueosa  and  muscular  coa  may  InS,^^^^^^^^  ^^f^""'"'  «'  the  necrosed 
-0  have  seen  in  one  case,  merely  the  dLendeH  ^^''*''^  ^^'^'^  ""til,  as 
"vcr  a  considerable  area  and  tMs  in  turn  r^  '""""'  '"**  """^  ^  '^^t 
the  euntents  into  the  abdomirl  rlvJfv^^^'',  ^''^  '''*^''  "berating 
■"",v  result  from  thrombosis  3  'thorT^  ^/"L''^'  '"^"'^t  formation 
mesenteric  veins  andl  fact  »n  ^  !•  T"*'  °^  obstruction  of  the  larger 
''"-'  i^  seen  in  v^^  us  and' "t  t"^^^^^^^^^^^ 

;'^'-«h  they  arlrtnoltmrSt'thTsf  ^^^^^  "^^'  "-- 

h"«n..r,  must  be  made  for  aTcddeveLm  't  ^'t".  '^"  "'^P*'""' 
varuoMfes  and  are  as  '  linfully  commo  '  -^^  """"  essentially 

^\e  rer.r  to  hemorrhoids  (pE      Th.?  ?'  "^  ™°>°»only  Painfu  . 

«"veral  factors:     (1)  Hate  of  n««;  "^  '  "^  *°  ^''^  interaction  of 

^ '■''>:  '-'^  to  the  suDerficLl   n  ^  f        congestion  of  the  rectal  and  ana 

^;'  ."-  "'-eased  rnSnTf1heT"*1  ""^'T  ''  *^^  -«'  -'" 
«t^""nn«  at  stool  and  (4    b  e,-,^„l    T''  '."'^"'^  ^^  the  act  o 
;:»'I'<^-tr  of  the  distended  vess?/^w!/^^^^  obstruction  to  the 

"" "-action  of  the  spJinc ter  anT    Th      "'*l "^T  *^"  ^'"bsequent 

'""^''  ■  "  less  complete  circle  of  nrnLr         '''"^* ''the prod ^.j^^^^^ 

I        circle  of  projectmg  varicose  vessels  at  the  anal 


548 


THE  DIG  EST  I VK  SYST      f 


ring,  external  to  the  sphincter,  whic-li  are  apt  to  In-  irritated  and  chhI 
by  the  passage  of  hard  feeal  matter,  which  may  undergo  rupture  and 
iiuhiee  severe  hemorrhage,  or  from  which,  again,  there  mav  mere 
he  oozmgof  blood;  or,  lastly,  the  contained  blood  may  undergo  throi 
bosis,  and  some  organization. 

Peptic  and  Necrotic  Ulcers.-  True  peptic  ulcers  are  now  well  reco 
nized  by  surgeons  as  by  pathologists  as  occurring  frequently  in  the  fir 
part  of  the  duodenum.  Ulcers  of  similar  nature,  producetl  by  dige 
tion  of  small  areas  of  necrosed  mucosa  are  rare  in  the  small  intestiii 
although  they  may  occur,  at  times  due  to  infarction  of  the  area  suppli( 
by  a  terminal  arteriole,  or  thrombosis  of  a  small  mesenteric  vin. 


Via.  240 


if;  , 


r,i 


Section  through  a  8.„„ll  simple  neorotif  ul.    r  of  ilcim,  involving  only  the  mucosa;     «,  Ucl«r. 
kiihnian  follicles;  b,  congested  vessels  of  subniucosa. 

faflammation.— DiHcrent  names  are  given  to  inflammatorv  dis 
turbances  accordmg  to  the  region  affected— duodenitis,  enteritis  (of  tlit 
small  bowel),  appendicitis,  typhlitis  or  cecitis  (of  the  cecum),  coUtis 
proctitis  (of  the  rectum). 

Owing  to  post  mortem  digestion  of  the  superficial  layers  it  is  bv  nc 
means  easy  to  gain  satisfactory  histological  pictures'of  the  various 
forms  of  inflammation  involving  especially  the  mucosa.  There  may 
have  been  all  the  clinical  evidences  of  an  acute  enteritis,  but  very 
little  may  manifest  itself  on  microscopic  examination  that  can  siirclv 
be  ascribed  to  acute  inflammation.  This  is  particularly  irue  of  simple 
or  catarrhal  enteritis  and  colitis.  If  the  mucosa  be  well  retained 
It  may  show  an  excessive  number  of  goblet  cells.  The  subimicosa 
also  may  present  pronounced  congestion  and  extensive  'eukocytic 
infiltration,  but  the  same  hyperemia  and  leukocytosis  are  features  of 
certain  stages  of  digestion  and  some  experience  is  needed  to  determine 
whether  these  exceed  the  normal  limits.  Petechial  hemorrhages 
iuggcst  an   abnormal  state,   but  superficial   necroses  accouipanying 


THE  IXTESTIXES  ^g 

;1^^n.edifficu.tto.Hstin.uishfro.„reasof„.oreextensi.ep^ 

tiK'  .ondition   mkrhe    onZ    ' 

infiltration  .,f  phle^ml^  frnw   h  a"ln7""''l"'^'  ^  «"P'>"r«tive 

--I  large  gut  so  inucTe.bg^lthatLfs  "id  ""."'"  "^-  ^"''j  •^'"«» 
tins  „f  inflammatory  origin  or  riis  it  m?J  ""*  Prominently.  Is 
ti.e  lymph  Glides  which  is  part  an  J  Tr  TJl  7  '^"'«^«^''n*^nt  of 
Ph.sia  common  in  childhoU?  When  th  5  Ir  'f  ^^''  '•''""'""'^  ^^JP^'^- 
kv  a  zone  of  congestioH^^ind  ne  t„  **^"/'f  ^'^^  «^^  surrounded  each 

-iK-n,  in  addition,  the  Lniitlr  '"««'»'"»t"'-y  causation,  and 

IS  (iKountercd   after  adolescence 

■iM.I  there  is  evidence  of  erosion 

over  these  small  nodes  and  actual 

ulcrratioM.  the  diagnosis  becomes 

still  more  assured.     It  is  more  par- 
ticularly m  the  colon  that  we  en- 

counter  such    folliculitis    in   the 

a'init,  while  in  chil.lren   in  diph- 

tHTiaan.l  other  acute  infections 

IH'  solitary  foliides  in  the  small 

"•wel  may  be  so  promii-ent  that 
tlH'  („n,hti(m  must  be  regarded 
iis  (it  inriammatory  ty^ 

tliocarum  and  colon  a.  .  t''''T"'>:/'"?r"**'^'^^'  """^t  "^'n  in 
P^'t..i,..s  over  the  ruLLndlr/nr  •  ?'  '''""•  '''^''  '"^^^^  "^  in 
WitI,  .leeper  extenS  of  L  P^jectrng  portions  of  the  mucosa 


Fia.  241 


— \tsr_ 
Lymphoid  hyperplasia  of   ileum    in   a    child 


..,..,,.1  -->^vi.:,iuii  VI  me  necrotic  proc< 

""^■""•-■...e,  extensive  ulceration  mav  ensue     THp  n~"";v '"^  •"'  "'"" 
«''n  m  Miercurv  and  arsenic  now!v  •  J  •    ^  condition  is  wdl 

»«n.iv..  ulceration  o   thT/a Th n^^r"'^  TT'  ""'J'  ^"'"^''^^^  ^^ith 

m-HM  k-sicTTn  tvn^ST^^^*°*?^**°^-~^yP^'~«»  Fever.-Thecom- 

^•'i^'-  with  no  recognizable  2n*-'r  1  ™.^^''  ^"^^^^er,  encounter 
'^tl..r.  inwhich  hesoltan  foS^^  '^',  '"^^'^^^  ^^'"Ph  "odes, 
•^«v(     ,,.„  onecaseiTwLht^        IV   *^ ''''''"  ^^^^^^  We 

»ltl-nd,  before  Heath  trn     ^  '''''*\'^'  "'^"'  ^"^  ^^  ^he  appendix 
^'tcr^h.thp  reSu  einf  ^'"''u*'?",  ^^"ber-VVidal  reacK  S 

pure  cultures  of  typical  typhoid  badlli  were  gained  from  the 


550 


THE  DIGESTIVE  SYSTEM 


1^ 


nor  does  the  severitr^  the  eaJ  and  thlf     '"  f  "'"'^""eously  affected, 
.lefinite  relationship  to  the  eitrntf.'''  '*"*^  '^P'^"  *°  ^ave  any 

and  adjacent  solita^  f«es\^   ot^g^^aSyi^^^^^^ 

well  above  the  level  of  the  rest  of  f^r,,,^       ^  swollen,  standing'  „ut 

congestion  or  distinctlv  pale  and  anem.rT'J'!,"  ^^^''''''."'^  ?™« 
at  the  same  time  but  commnnlv  fK  *,"  "'^  "'**  involved 

affected  and  oth  rs  IrrTmot^exrhiT":;-  '"  l^'  ""'-"^-"^  ^""- 
possible  by  the  studv  oronecTse  to  follow  T  '**^'''  '*  ''  **  *'"'«« 
the  earliest  is  seen  to  b^  an  „tVf«  u  •  ""*"?'  '^*«^"«-    ^  these 

of  the  Peyer's  patches  Section?  l^^T  ^''\^  "^°"  ™t«  «^«"ing 
rounded  by  a  hCeSc  zone  a,  d'^t''"'  'K  '"I'T'^""'  f«"'^'««  «"'' 
with  large  cellsTtheendot'h^?!  *  ^"^^^'''^  J^'^Ph  spaces  filled 
activelv  phagocvtic  and  mav  nnn.  •  T  ("^^^ophages).    These  are 

andtheir^emLl^r'inS  :    Xl^^^^^^^^^^^^^^  \^  «'T'^'- 

of  active  proliferation  of  Ivmphocvtes     At  „  W       *         '.^^^^ 

toberendereclanemicTdpaTe  ''  ^''''"^  ^'^^  *'"''  ^^"^  ^^ 

day5:-t';ols''SL^tr  ''""*  *''^.*^•^'^*^  *«  *h«  "'-t-^h 

phSes"  sh^ :y^o7"d^g:    raTo^nrdt^^^  Z'i^if  ^'  "'"-- 

tTtrttr^fTnti^nr  4^^^^^^^ 

the  stretche?  oveSn^ Ic"?/^  Se'd  ^"--«'\-hich  i'nvolves 
with  fecal  Diement    .rS  K^  •     J      .       u  ^^^^"^  """^^s  ^^come  staine<l 

widespread  TougLiJ^apfJchth"''^  ""l"    ^^'^'T  *^^  P—  '^ 
produced;  the  sSlLjff'    u       ""^l  ^^  *  '*"'^"«  appearance 

the  patch  nVldleTwi  rlnrallSLrT,^^^^^  °"*'  '^"^'^"^ 

deserves  note  that  the  who  e  of  Tl!  [  P^fojations  («tat  cribMe).    It 

proceed  to  this  stage  o?  neLsssrth-^t'w^^^  ""'  ''''"  -T^^^^"'^^  *" 
which  the  sloughini  afflTsonJy  one  port iL"'^  ""'  "'^'^  ^^^^'''^^  "' 


THE  IS  TEST  INKS 


551 


m 


552 


THE  DIGESTIVE  SYSTEM 


theaffect«l  individ.mlZe  l^hTuf  -'"^  ^« '"volve  the  whole  of 
be  formed.  In  t  Si  ^n,!;  h  li7'''f'';r?"*-'*."'"«^  ^'""R*'^  '"a^ 
tutinir  the  Pevp?,  n!i  7  1      .      '°'*'  ^'  **»«  lynjphoid  tissue  consti- 

hanging  c  gra  formed  of  fl»  lr,(.rf  »...  .  "V"™"'  W  "".«<l  ovcr- 

(rom  btneath  ,hich  the  llmlhM,^       u  °'  '"'  ?°'«^»  "'  ""e  patch 
axi,<»rmp„n,li„r«i  h  theTot^ifoTL  •?  ''°j'^  ""'J  »'  " '""« 

.he^e.nteHe':.2„rni' CrXa;;;;',„K:^S^X,'r 


ttSoTt^eT-rvt^erh^'Ltrit;'"'  "-^  r-"">-  - 

the  lymph  n«le  but  a  J  the  's,^„^„3^  "i^*^"  "»'  "<"  ■»*" 'y 

.ff«e,,  by  ti,e  nee  Jra^&t  P^:'  °'  """"""'"  "-  -" 

»om:whrral/'^"^',^!;"t.t'™i:5V'*''>--:'^^ 

floor,  and  n„„  the  mSxHrmTmbr.?e  "*  ''°''"  '»'*  """""^  «°  «l>« 
with  a  smooth  shiny  l"™"  of  erthX,;  "«^r""."8'  «»;?'»  that  floor 
tion  tissue  produced,  aS  Httr.  r  ,,'  k  '""  "  ^"^  "«"'  8»a"la- 
death  ooeu,?  .  few  Intis  ater  5|  thattSr'  contraction.  Where 
small  OV.I  .re.  where  the  wTis'l'hfa'ner'2n'"n„™*  °'"  "  '  """"■ 

of  The  ofdret.'rf  XSd  Sr™"';*'^*''-  "■«  -»"*«»" 
that  c«es  are  not  LfZ^ent  ^^«hS7h  '"  u'  ^"'r  «''  "^P<"" 
'ourth  week  or  later,  Z^L'^^^^IT^'t^-^^J^t 


THE  tSTBSTINES 


653 


Peyer's  patches  at  the  end  of  t  first  .veek.  Progressive  involvement 
of  lymph  nofles  explains  the  long-continued  cases;  where  successive 
crops  of  nodes  are  affectwl  at  intervals  we  obtain  rcUpMt. 

Similar  necroses  are  liable  to  occur  in  the  mcsenter'  lymph  ncMles; 
the  lymph  mxle  situated  in  the  ileocecal  angle  is  coni<tantly  enlarged 
in  typhoid  and  is  particularly  apt  to  exhibit  whitish  areas  of  necrosis. 

The  two  grave  eomplicauons  of  the  typhoidal  process  are  hunorrhaf* 
through  erosion  of  a  vessel  or  vessels  in  the  sloughing  stage,  and  per- 
foration,  either  thnjugh  extension  of  the  necrotic  process  into  the  muscu- 
lar layers,  possibly  along  the  lymph  channels,  penetrating  thaf  muscle, 
or  through  rupture  following  pressure  of  the  bowel  contents  pon  the 
weakened  area.  Most  often  the  perforation  is  small,  of  the  "  i-point" 
variety,  suggesting  tin  former  mode  of  origin. 

TuberculoBii.—Tuberculosis  may  involve  any  portion  of  the  small 
iiiul  large  intestines,  and  has  no  special  site  of  election,  save  that  where 
infected  feces  become  arrested  in  the  lower  part  of  the  ileum,  in  the 
ciecum,  sigmoid,  and  rectum,  there  "nfection  is  most  liable  to  occur. 
Although  it  oftenest  originates  in  >!  jividual  lymph  nodes,  there  is 
not  the  same  strong  tendency  to  iinu,  ite  primarily  the  nodes  immedi- 
ately above  the  ileocecal  valve,  and,  what  is  more,  in  the  subsequent 
st:'Kes  the  process  spreads  beyond  the  limits  of  the  nodes  and  patcl  :,, 
involving  all  the  coats. 

The  infection  may  be  (1)  of  hematogenous  itrigin  (acute  miliary  tuber- 
culosis; this  rarely  sets  up  extensive  lesions),  or  (2)  of  enterogenous 
origin,  from  the  bowel  contents,  or  (;i)  peritoneal,  by  infection  from  the 
peritoneal  fluid  secondary  to  ovarian,  tubal  or  other  abdominal  tuber- 
culosis.   This  last  will  be  discussed  later,    it  is  the  enterogenous  that 
causes  the  most  characteristic  lesions.     This  may  be  primary,  fmm 
the  fotnl,  and  then  most  often  set  up  by  the  bovine  type  of  baci 
(milk),  or  secondary,  due  to  swallowing  of  sputum  where  there  ex. 
pulmonary  or  laryngeal  tuberculosis  (human  type).     Sayi  ig  this,  a 
must  be  remembered  that  infection  with  the  bovine  type   ^lows  itself 
most  often  not  in  the  intestinal  wall  b-it  in  the  mesent'  -i"  nodes. 
It  has  been  abundantly  proved  by  experiment  t  •  r  tht-  tube;  J.  bacilH 
may  be  carried  through  the  bowel  wall  without      ..ing  up  any  lesion, 
only  becoming  arrested  in  the  mesenteric  nodes.    The  bacilli  carried 
tlirough  the  mucosa  may  become  arrested  in  the  submucosa,  and  there 
most  naturally  in  some  lymph  node  or  collection  of  lymphoid  tissue  along 
the  course  of  a  lymphatic.    Thus  there  develops  a  submucous  tubercle, 
and  bacilli  escaping  or  carried  from  this  induce  the  formation  of  sec- 
ondary tubercles  in  the  immediate  neighborhood.    These  in  their 
growth  iuse  and  undergo  central  caseation,  cut  off  the  nutrition  from, 
and  even  invade,  the  overlying  mucosa,  and  necrosis  and  ulceration  is 
the  result.    The  subsequent  stages  are  those  of  progressive  extension 
of  the  lesion;  new  tubercles  form  especially  along  the  course  of  the  lym- 
phatics and  as  these  lymphatics,  like  the  blood  vessels,  hav^  a  circular 
disposition,  the  tubercle  formation  and  ulceration  is  peculiarly  apt  to 


r.c. 


554 


m\  I 


h:  1 


THE  DIGESTIVE  SYSTEM 


be  most  marked  in  a  trunsNerse  .lirectio...  often  becominR  completely 
annular     Other  yraphatics  penetrate  the  mnscularis  and  tE    S 
taneonsly  tubercles  become  formed  on  the  serous  aspect  of  the  1 
Thee  groups  ol  subserous  tubercles  are  tiie  first  indication  of  the 
con.lit.on  upon  uispectinj;  the  opened  abdomen 


Fio.  1J44 


TuberculDiia  ulceration  of  the 


(McCjiII  Pnlh    Mu».) 


FlQ.  245 


Syphilitic  piTiproctitis.     Portion -f  thu  lower  i-n  I  „f  fi,„  ,    .  u 

K  Jnlr       'r*^*''  ''"^  ^'  >^'*'^  irregularly  swollen  bv  the  presence  of  under- 
irreoULir,  tornied  ot  u  layer  of  tubercles  or  of  these 


THE  INTESTIXES 


alternating  with  caseating  areas.  This  caseation  and  ulceration  may 
extend  into  the  muscularis,  which  forms  no  natural  boundarj*.  Where 
this  extension  is  marked,  there  also  is  well-defined  subserous  tubercu- 
losis, and,  secondary  to  this,  a  notable  tendency  to  the  formation  of 
local  adhesions.  Those  explain  why  in  intestinal  tuberculosis  per- 
foration and  perforative  peritonitis  are  comparatively  rare,  while 
the  formation  of  fistulous  communications  between  various  segments 
of  the  bowel  is  comparatively  frequent.  We  have  encountered  half  a 
dozen  of  these  in  a  single  case.  The  disease  is  apt  to  be  chronic  and, 
what  is  more,  to  show  healing,  fibrosis,  and  contraction  in  one  area, 
while  in  the  immediate  neighborhood  new  tubercles  may  be  forming. 

The  largest  of  these  annular  ulcers  are  to  be  met  with  in  the  caecum 
and  colon. 

Tuberculous  ulceration  involving  the  mucosal  pouches  formed  by 
the  contraction  of  the  sphincter  ani,  leads  to  one  form  of  fistula  in  ano. 

Syphilis. — Save  in  connection  with  the  rectum  (and  the  character- 
istic lesions  there  are  now  coming,  by  some  at  least,  to  be  regarded  as 
doubtfully  of  syphilitic  origin),  acquired  syphilis  rarely  affects  the 
intestinal  tract.  A  form  of  lesion  is  described  as  affecting  more  par- 
ticularly the  jejunum,  in  the  form  of  groups  of  small  nodes  arranged 
in  a  circular  manner  in  the  submucosa  which,  under  the  microscope, 
presents  vessels  with  characteristic  perivascular  small-celled  infiltra- 
tion. The  mucosa  over  these  is  apt  to  ulcerate,  leading  to  transversely 
(lis|)osed,  somewhat  shallow  ulcers  with  uneven  pale  floors. 

What  until  recently  was  held  to  be  a  syphilitic  proctitis  and  peri- 
I)roctitis  is  a  remarkable  condition  of  venereal  origin,  presenting  a 
combination  of  ulceration  and  irregular  hyperplasia  of  the  rectal 
mucosa  through  the  greater  part  of  its  course,  with  fistula  formation 
and  the  production  of  periproctal  abscesses.  Sections  show  a  pro- 
nounced plasma  cell  infiltration  throughout,  without  the  small-celled 
ptTi\ascular  infiltration  so  common  in  syphilis  being  a  leading  feature. 

The  intestines  are  more  frequently  found  infected  in  congenital 
syphilis.  The  commonest  form  is  a  diffuse  small-celled  perivascular 
infiltration  of  the  submucosa  and  muscular  coats,  but  the  development 
of  scattered  guniiuas  has  also  been  recorded  and,  more  frequently,  of 
multiple  miliary  gummas  of  the  submucosa  and  muscularis,  closely 
allied,  we  may  suggest,  to  the  first  form. 

Appendicitis. — All  the  aspects  of  appendici*^'s  are  now-a-days  treated 
in  such  full  detail  in  the  text-books  of  surgery,  and  the  student  is 
expected  to  have  so  thorough  a  knowledge  of  the  subject  thai  we  find 
ourselves  in  a  dilemma.  To  fulfil  his  needs,  to  discuss  the  etiology, 
classification,  histology,  and  sequels  on  the  same  scale  as  does  the  surgeon 
would  consume  many  pages  and  be  out  of  balance  with  the  treatment 
here  afforded  to  other  important  conditions ;  to  indicate  briefly  the  main 
data  may  lay  us  open  to  a  charge  of  neglect.  Nevertheless  as  the 
student  gains  these  data  elsewhere  the  latter  is  the  course  we  must 
select. 


r 

;;i 

.■<!      i 


556 


THE  DIGEST  I VE  SYSTE.\f 


;j:f"r™iirs;;™'ir'K;r^:,,,-r':itt 

tl  e  s„Y!,„B  „u,«,l  by  the  p,„«„„.  „r  tl,e»  „  ,l«  cause"  the  „ufc 
at  on  of  ,„„,lry  |,atl,oge„i,.  „rB„„i,„„  (p„.n,Uoa.„;  if  t™l,<Z" 

.i;e  i,.;iK|a:r;;  ^h  ;;^l"  ^h:!™sr„:*  :;;i:!^eS 

retauK-d  matter,  a,„l  so  seemingly  predisposes  t„  the  T^ZZnof 
eatarrhal  and  graver  inflammations.  It  must  be  a.LiXl  J k.  t U. 
a  relatndy  slight  catarrh  extending  from  th   eLum  ^^  4,"  "'-^^^^ 

^z:\:^'7^  rr'T  -^  ^^^^ ""™  tube.uislimZ 

contents  n.  the  <hsta!  portion  and  all  its  sc.uels.Sveelnnot  accept 


THE  IXTESTIXES 


the  view  recently  propoundodhy  Metchnikoff  that  pin-wonns  and  thread- 
worms (oxyuris  and  triehocepha!'is)  penetratinj;  the  mucosa  are  a  domi- 
nant cause  in  setting  u|)  infection,  v.  !>ih-  ailmittinj;;  that  they  are  present 
in  a  small  proportion  of  children  exhii.'^'njr  a  milder  form  of  catarrhal 
ai)pendicitis.     Briefly  all  these  factors  signify  imperfect  drainage. 

By  analo(;y  with  what  we  know  regarding  the  earliest  stages  of 
infections  involving  the  lymph  nodes  in  the  ileum,  namely,  typhoid 
iiiid  tuberculosis,  we  are  inclined  to  the  view  that  bacteria  are  conveyed 
into  the  submucous  lymph  nodes  without  there  being  necessarily  any 
Drcliininary  destruction  of  the  surface  epithelium.  Wherever  there 
is  irritation  from  within  the  lumen,  a  sin:,)le  catarrh  is  the  first 
disturbance,  with  increase  in  goblet  cells,  congestion  of  the  sub- 
nuicosa,  and  increased  passage  outward  of  wandering  cells,  and 
tliese  cells,  we  believe,  convey  the  bacteria  into  the  underlying  lymph 
nodes.  Thus  while  hesitating  to  oppose  the  masterly  studies  of  Aschoff, 
we  are  accustomed  to  conceive  the  process  as  affecting  essentially  the 
1,\  inj)li  nodes.  It  is  the  active  proliferation  of  the  cells  in  these  nodes, 
iiiid  the  consetpient  swelling  with  accompanying  small-celled  infiltration 
of  the  siibmucosa  and  muscularis  that  in  our  experience  is  the  dominant 
feature  in  acute  appendicitis.  Further,  as  a  result  of  the  swelling, 
rather  than  as  a  normal  condition,  sharp  angles  or  pits  of  the  mucosa 
beconu  developed  which  clearly  favor  bacterial  growth,  necrosis,  and 
ulceration  t)f  the  mucosa.  This  we  regard  as  a  second,  rather  than 
ns  a  first  stage. 

The  condition  apparently  may  proceed  no  farther  than  this  and 
tlun  become  arrested,  with  little  or  no  after-affects;  or  with  the  great 
swelling  of  one  or  more  lymph  nodes  the  overlying  nuicosa  undergoes 
nccrosi'-  and  removal,  and  with  resolution  a  scar  is  i>roduced  with  some 
(onstriction  of  the  lumen  (simple  catarrhal  appendicitis.) 

Generally  we  observe  more  than  this.  It  is  a  striking  feature  of  the 
iipiM-ndix,  due  possibly  to  its  small  size,  that  once  set  up,  inflammaticm 
li'iids  rapidly  to  involve  all  the  coats.  The  limits  of  the  alfected  lymph 
nodes  become  ill  defined,  small  roun<l  cells,  lymphocytes,  and  poly- 
morphs infiltrate  the  circular  and  longitudinal  muscle  layers.  Kven 
the  subserous  vessels  exhibit  intense  congestion,  and  at  an  early  jieriod 
t!rc  may  be  a  i)eri-appen(licitis  with  fibrin  formation  on  the  serous 
-I  <■(',  long  before  there  is  any  deep  necrosis  or  sign  of  perforation. 
That  this  stage  (^diffuse  appendicitis)  is  also  recovered  from  is  indicated 
l>y  the  fretpiency  with  which  we  encounter  its  after-etlVcts,  the  so-called 
clironic  appendicitis,  seen  where  the  appendix  is  removed  after  recurrent 
attacks,  and  characterized  by  diffuse  fibrosis  involving  all  the  coats, 
and  by  the  orgaiiize<i  adhesions  surroimding  the  organ. 

If  the  inflammation  be  more  pronounced,  the  local  toxic  t'tfects  of 
the  bacteria  cou|)led  with  the  inflanunatory  stasis,  acting  most  power- 
f"ll\  in  the  region  of  primary  invasion,  lead  to  deep  necrosis  and  ulcer- 
.(tioii  which,  extending  tlirougii  the  outer  coats,  cause  perforation 
(perforative  appendicitis).    Where  the  inflammation  is  more  widespread 


558 


77/ A'  DIGESTIVE  SYSTEM 


ami  tlie  stasis  an.l  necrosis  affect  the  greater  part  „f  tl.e  .listal  portion 
or  even  the  appendix  as  a  whole,  widespread  gangrene  ens^s  (i^^^l' 
ojis  appendicitis)  an.l  at  operation  little  may  be.  foimd  save  ^  d'^Zj 
s^ongh    ying  in  an  abscess,  ,>r  a  more  diffuse  collection  of  ',nl  ion 
Hind  with  admixture  of  fecal  matter 

The  further  effects  .lepen.l  largely  upon  the  position  of  the  ap,K«ndix- 
Nl.cther  It  pass  down  into  the  true  pelvis,  or  be  retroperitoneal    «; 

appendix;  iepend  upon^he  reactive  power  of  the  individual-  denend 
also  upon  the  nature  of  the  infecting  organism.  Thus  here  m'v  be 
a  localized  pen-appendical  abscess  well  circumscribecl,  a  ™ii,^ 
retropentoneal  inflammation,  a  rliffuse  peritonitis,  an  in  ense'tovllj 
atal  before  generalized  peritonitis  shows  itself,  a  pvlephlebSextSTn.t 
a„ng  the  veins  ot  the  appendix  to  the  larger  mesenttk  ^  eins  and    o  Jo 

Colitis-Colitis  may  be,  as  alrea.ly  stated,  of  verv  varied  orders 
m.mely,  simple  catarrhal,  follicular,  membranou;..  ulcerative  am  othe  ' 
Certain  forms  deserve  additional  notice.  Mucous  colitis  iT^  remarkable 
condition  ,n  which    from  time  to  time,  the  indivi.lud  pa  ses  casts  o 

n  .     !!^{!  T'*'  "?^"'*  ^"*'^^''^'  "^  °^"^"«'  ^vhich  mav  be  mTnv  inches 

n   ength;  the  con.iition  may  extend  over  manv  months  "nd    af"er  a 

enod  of  quiescence,  may  recur.     It  is  unaccompanie<l  bv  an v  marked 

bnle  reaction  and  it  is  doubtful  whether  it  should  be  spoLrof  as 

nflammptory  m  nature,  seeming  rather  to  '  e  of  the  nature  of  a  secretorv 

neurosis;  ,t  occurs  most  frequently  in  young  women  and    u.se  ofTeuroS 

temperament,  and  possibly  it  is  associated  with  cond  t  oL  of  "S  t 

S^'axr'  ^''"^^"^^"- '' '' '-"-''  ^-"'  by -tl:/t! 

Of  the  specific  inflammations  of  the  colon  two  especiallv  destne 

m™  ,ra,,,.  ,s  swollen  and  h.vptrennc,  with  a  pro,,,,,,'™  IZlZTZ 

pSlarv      -^^^^  ^"  •"^■"^'^  ^'"^''^-'"R  "f  the  »>oweI  with 

paj)iiiar>    o\trgrouth  oil  the  remaining  mucosa.     EntamcebH"  are  to 


THE  n  '-ESTINES 


559 


Epid:r^c  bacillary  colitis  (dysentery)  shows  sorrif  (iifference  accorcling 
to  the  strair.  oi  badlhis  that  is  the  causative  agent.  The  more  severe 
type  is  that  found  in  the  tropics  and  in  Japan,  due  to  Shiga's  bacillus; 
this  is  strongly  epidemic.  In  North  America  a  somewhat  milder  form 
is  encountered,  particularly  in  inmates  of  asylums  and  other  institu- 
tions, and  in  infants,  causing  one  form  of  sunmier  diarrhiea;  this  is 
(hie  to  the  strain  isolated  h\  Flexner,  as  well  as  toallied  forms.     In  these 


ficcrative  colitis,  showing  multiple,  deep  ulcers  (a)  mostly  transverae.     (McGill  Path.  Mus ) 

Fig.  247 


Colma  polyposii  apparently  secondary  to  old  inflammation,  showing  at  a  an  outstanding  polyp. 

(McGill  Path.  Mus.) 

l)a(il!ary  cases  the  rectum  and  .sigmoid  are  as  apt  to  he  involved  as  are 
tile  upper  reaches  of  the  colon.  There  is  intense  congestion  of  the 
mucosa  with  .swelling  and  prominence  of  the  rugse  and  superficial 
necrosis  of  the  mucosa  leading  to  the  formation  of  a  membrane,  and 
leading  also  to  erosion  and  ulceration.  Tiiese  ulcers  in  the  earlj  .stage 
are  most  apt  to  be  along  the  ridges  of  the  mucosa,  while  in  severe  cases, 
a  purulent  infiltration  of  the  submucosa  may  ensue.  The  thickening 
of  the  submucosa  is  never  so  marked  as  in  the  amoebic  form,  nor  is  the 


ofiO 


THE  DIGESTIVE  SYSTEM 


bowd  wall  s«,  niarkejily  tliickene.l.     Both  f(,rms  of  colitis  are  character 
•ze.   hy  .iysentery  which  may  he  „f  lo„«  continuance.  ^'^^''^^t"- 

Heference  has  already  been  nia.le  to  tuberctfous  coUtis  and  to  the 
ma^t  charactenstjc  form  of  proctitis,  the  so-calle,l  syphilitic 

Progressive  Changes.-  As  alrea.ly  stated,  hypertrophy  of  the  bowel 
occurs  above  any  region  of  chronic  obstruction 

Tumors.  _-It  may  he  said  of  the  small  intestine  that  primary  tumors 
of  any  order  are  .hstmctly  infrequent,  and  of  the  large  intes'tineZ 
benign  tumors,  suye  napillary  growths,  are  rarely  met      XeSe Is^ 
oases  are  on  record  of  various  forms  of  benign  tumors  of  the  intestines' 
fibroma,  bpoma  (either  subser.>us  or  submucous),  myoma  (.litto),  he;^- 

SThe  blrtl      '*""'•     ^^ '"'•^  \^'''  *"™°"  ''"»J-t  ^»to  the  lumTn 
ot  the  bo^^el  they  may  cause  either  ob-truction  or  intussusceotion 
PapUloma..,  whose  epithelial  porti<.n  is  o;  the  c.,h„nnar     ™re'X 

ZZ^l  ":  "T  "'•;•"  *'"*''"  i"  *'"'.-^'"''^"  '"^^^^t'"*^ «"'!  "ft^^n  are  second    y 
to  previous  ulceration  ami  continued  inflammation  (Fig  241)      They 

trZun^'S  w'r:r"T-  /^"^  •^^"'"  ^^'^^^^^^  immediately  around 
the  anipulla  of  \ater,  the  duodenum  is  singularly  devoid  of  tumors. 

Ut  malignant  growths,  we  encounter  carcinoma  in  the  dumlenum 

the  small  mtest  ne;  it  is  more  common  in  the  colon,  especially  at  the 
flexures,  and  still  more  common  in  the  rectum.     The  next  mos   frtTnent 

c^me':  tti  T  '"'Y  *';  r"''-    ^^  ^^""'^ '"  «enerLT^he  r?c  urn 
comes  litth  m  th;3  order  of  frequency  of  incidence.    The  forms  that 

?;X'  rf  S;"l  •"  ^  '"«•"'  -/"-nar-ceHed  ad^norinoma 
forms  Lr.i,.^        ^'       "t'^  ''■-  ""r   ^''"  •'"^•""nter  more  infiltrati.  , 
torin.s  ies.>  adenocarcinomatous  in  character,  with  scirrhous  tendencies 
encircling  and  infiltrating  broad  areas  of  the  bowel  with  accompanWng 

i^lithelioim,  '""'"■  "     '  "^''"'  '"  *^"  ^"••''  ^^*^'""'  ^q"'*™""^ 

of'^the  d?ll"r'.  'T  \'lf'''^^''^^  ""'"^■'•ous  examples  of  carcinoma 
l,nW  ;  '  ""  "^  *''*^  »I'I>e..dix;  the  form  is  usually  of  the 
smplex  or  the  scirrhous  type,  and  what  is  very  remarkable  is  that  w  th 

a  d  no'rn^^  ttk''  "<•  s.vmptoms.  and  what  is  more,  little  infiltration 

defined  \C  ,  .  •  "T*""'  "/  ^'''''''^  ^'^'''  ^'^^^  «™«»  «»d  well- 
defined.     Wv  have  here,  in  short,  the  paradox  of  a  "benign"  carcinoma 

lllTreof  tf  ""''"  *  "'>'^  ""  --■— "f  the  loteriofTle 
Ileum  are  ot  the  same  benign  type. 

maT*'n.!"ss  on\o  ^T'T  "\'^'  '"*''^'"'^'  "^^  "^"«»>-  "Iteration,  which 

i  fi  tr  'ive    vn     '    •"™*r";/*|'*  ""''"''  frequently  the  growth  is  of  the 

1     e.u   r      •  ^     r;  "^'  ''"^''  '••■  '*'  P'-"i*'^tion  into  the  lumen  ami  bv 

the  coiitract.on  of  the  gut,  to  stenosis  and  obstruction.    Hemorrhages 

'  efreauentin"tr"T'  '"  •;  *^\--  ^^  S-t"c  cancer.    Metasta!  s 

Se  IherT'  o  k     fr^'^'r*""™ 'J^^^P^  '™'^^  ^"^^  ""  t^'^  perituneum; 
Ihe  hvtr  a.so  is  a  frequent  seat.    Secondary  carcinoma  of  the  intestines' 


THE  PERITONEUM 


561 


is  not  common;  cases  are  on  record  in  wliich  a  priniarj-  cancer  of  the 
-tomacli  has  been  followed  by  one  or  more  solitary  growths  along  the 
(durse  of  the  intestine.  There  may  further  be  infiltration  by  extension 
into  the  rectum  of  uterine  carcinomr.. 

Primary  sarcoma  mav  occur  as  a  round-celled  growth  originating 
u'liuTiilly  in  the  submucosa,  and  this  most  frequently  in  the  lower  part 
iif  the  ileum,  though  the  rectum,  cecum,  and  even  the  appendix  furnish 
ciiscs.  Spindle-celled  sarcoma  is  distindy  rare.  Lymphosarcoma  has 
the  same  regional  distribution  as  has  the  round-celled  sarcoma,  and 
l)()ssibly  they  often  fail  to  be  distinguished  one  from  the  other.  Second- 
ary sarcomas  occur  in  cases  of  generalized  sarcomatosis;  melanotic 
sarcoma  ■  particularly  are  apt  to  show  themselves  in  the  bowel  wall. 


THE  PERITONEUM 


Were  it  not  for  the  necessity  of  peristalsis  and  motility  of  the  stomach 
and  intestines,  the  peritoneal  cavity  might  be  considered  a  superfluity. 
All  those  organs  whose  function  demands  a  change  of  size  and  positi(m 
are  surrounded  by  a  lubricated  cavity  in  which  to  work,  and  of  these 
(•a\ities  the  peritoneal  has  by  far  the  largest  potential  extent  and 
actual  surface.  We  must  take  it  for  granted  that  the  student  is 
lainiliar  with  the  anatomy  of  the  peritoneum,  the  disposition  of  the 
liarictal  portion,  the  nature  of  the  mesenteries  whereby  the  viscera 
I'aiig  relatively  free  within  the  cavity,  and  the  relationship  of  these 
nicsfiiteries  to  the  blood  supply,  whereby,  while  the  bowel  is  allowed 
a  large  measure  of  freedom  and  of  variation  in  calibre,  each  part  is 
proventcd  from  escaping  beyond  a  certain  f^xed  distance  from  tae  origin 
nf  the  mesenteric  vessels.  We  must  expect  that  the  student  is  familiar 
also  with  the  anatomy  of  the  great  omentum  and  its  relationship  to  the 
stomach  and  the  transverse  colon  respectively.  The  great  addition  to 
the  su])erficies  of  the  lining  membrane  of  the  peritoneal  cavity  afforded 
by  the  great  omentum  has  for  long  attracted  notice  and  numerous  hyp  j- 
tlieses  have  been  suggested  to  explain  its  action.  It  is  eminently 
\ascular,  its  vessels  being  almost  in  contact  with  the  contents  of  the 
peritoneum,  so  that  if  any  portion  of  the  omentum  finds  itself  in  an 
area  of  irritation,  there  is  rapidly  excited  in  it  a  secondary  inflammatory 
l)n)(ess,  and  the  ease  with  which  it  forms  adhesions  that  are  temporarily 
lirotcctive  is  very  remarkable.  W'ith  so  large  a  free  surface  as  that 
atl'orded  by  the  peritoneum,  it  seems  necessary  to  have  some  such  pro- 
tective organ  to  produce  a  rapid  exudation  of  protective  bodies;  whether 
absorption  occurs  through  it  with  the  same  freedom  deserves  further 
-tiuly.  The  general  indications  are  that  foreign  particles  present  in 
I  111'  i)eritoneal  cavity  make  their  way  with  greatest  freedom  into  the 
I.Mnph  spaces  of  the  diaphragm. 

The  peritoneum  is  constituted  by  a  layer  of  endothelial  cells,  ,:.i.  h, 
\\  liile  thin,  are  by  no  means  inert,  and  rapidly  react  to  any  inflammation, 


5*12 


rHK  niCKSTIVE  SYSTEM 


lis 
\l 


Iky 

utuIprKoing  swflliiif;  and  often  proliferation.  These  form  a  oontinnouf 
inemhrane  honnding  the  cavity  save  at  two  points,  viz.,  the  opening' 
of  the  FaMoi)ian  tul)es,  tliroiijjh  whieh  there  is  a  potential,  thoii>;|i 
rarely  actual,  comnniiiication  with  the  exterior.  So.  also,  it  must  Ik 
reineinLered  that  o\»-r  tlie  ovaries  the  peritoneum  becomes  modifiid 
mto  a  more  cubical  layer  of  cells,  the  germinal  epithelium,  from  which 
by  downiirowths  oripnate  the  ovarian  follicles.  Heiieath  this  endo- 
thelial layer  is  a  subserous  layer  of  loose  connective  tissue  which  in 
certain  regions  shows  a  pronounced  tendency  to  undergo  metaplasia 
into  fat  cells,  as  in  the  ap|)endices  ej)ii)Ioicie.  the  mesenteries,  and  the 
omentum. 

Abnormalities.-  Of  abnormalities,  jn-rhaps  the  one  most  frequently 
noticed  is  a  \  ariation  in  the  length  of  the  great  omentum,  which  may 
vary  from  a  small  irregular  fringe  an  inch  in  length  to  a  nuissive  ai)ro"n 
otten  loaded  with  fat,  a  foot  or  more  long.  Similar  variations  are  at 
tunes  to  be  noted  in  the  mesenteries,  most  marked  in  the  case  of  organs 
which  normally  are  incompletely  surrounded  by  peritf>neum.  but  may 
on  occasion  be  fouii.l  to  possess  mesenteries.'  c.  «/..  the  cecum,  anil 
ascending  colon,  and  even  the  kidney  ("floating  kidnev").  We'havc 
already  referre<l  to  abnormal  length  of  the  mesosigmoid  as  favoring 
the  development  of  the  condition  of  megacolon  (Hirschsprung's  disease) 

Circulatory  Disturbances.— The  great  vascularity  of  the  peritoneum 
renders  it  most  sensitive  to  circulatory  .listurhances.  Where  there 
IS  anemia  its  pallor  is  marked;  where  there  is  hyperemia,  aetive  or 
passive,  tiie  injection  is  extreme. 

Passive  congestion  is  accompanied  by  })r<)nounced  transudation  and 
production  of  ascites;  even  after  death,  transudation  easilv  occurs,  so 
that  where  immediately  before  death  there  has  been  a  transfusion  of 
sahne  solution,  or  after  dcatii  an  injection  of  emlialming  fluids,  thei)eri- 
toneal  ca\  ity  may  be  found  to  contain  a  considerable  amount  of  fluid 
which  must  not  l)e  mistaken  for  that  of  ascites.     Apart  from  circulatorv 
disturbances,  it  des»>r\es  note  that  +he  presence  of  ov.vrian  tumors  is 
fre(]uently  accompanied  by  a  noticeable  grade  of  ascites.     The  exact 
cause  of  this  is  somewhat  obscure.     On  p.  ;}(i(i  we  have  already  disc.isse.l 
ascites,  and  the  related  i)henoniena.     How  sensitive  are  the  peritoiical 
vessels  IS  well  shown  when  the  perit(.neum  is  seen  at  operation  even 
)ut  a  tew  minutes  after  a  i)erforation  of  the  bowel;  there  may  bo 
ittle  obvious  escape  of  bow<.|  contents,  yet  the  intestinal  coils "mav 
be  of  the  most  angry,  scarlet  color.     It  will  be  understood  from  this 
tliat  capillary  subserous  hemorrhagea  are  not  uncommon,  especiiillv 
where  there  has  been  soin.'  toxemia  with  degeneration  of  the  capillar^ 
eiuh.thelium.     A  favorit.-  seat  for  these  hemorrhages  seems  to  be  the 
lower  anterior   half  of  the  parietal    peritoneum.     Thev  are  seen  oar- 
ticularly  in  severely  toxic  conditions,  as  well  as  in  the  hemorrhagic  dis- 
eases.   Of  gross  hemorrhag.s  into  the  peritoneal  cavit\-  the  commonest 
and  most  oxiei.sive  is  that  seen  in  ruptured  tubal  gestation,  and  in 
traumatic  rupture  of  the  liver,  spleen,  mesentery,  and  other  organs. 


THE  I'ERITHSELM 


563 


'I'lif  ctfects  of  thrombosis  and  embolism  iip<(n  the  visccTii  are  so  >jrave 
that  the  acconii)ari\  iiij;  chaiiKi's  in  the  i«Titoncuni  are  rdativ«-|v  of 
ininor  importance,  alth.niKh  they  are  of  a  like  nature,  viz.,  stasis, 
iKinorrliane,  ami  neerosis. 

Inflamznation.-  Peritonitis.— Without  utternptinj;  to  make  any  full 

cliissifieation  of  the  various  aeute  inHamm.itions  of  the  peritdneum 

Irtim  a  surgical  standpoint,  it  may  l)e  hiid  (h)\vn  in  tlie  first  phiee  that 

three  t,\  pes  are  to  he  distinguished  at  autopsy:   (1 )  local  circumscribed, 

VI)  locally  diffuse,  and  Ci)  universal.     We  may  find,  tliat  is,  that  hy  the 

nipid  imxluetion  of  adhesions  and  the  formation  of  fibrin  an  inflamma- 

tii.n  is  sharply  eircumserihed  to  the  rejjion  of  primary  disturbance. 

\\V  may,  for  example,  find  an  api)endix  bathed  in  pus  which  thus 

lorinsa  i)eri-ai)pendical  abscess,  and  through  omental  adhesions  and  the 

(ilirinous  adhesions  '  "tween  surrounding  coils  of  intestine,  the  rest  of 

the  peritoneal  caviiy  wholly  closed  off  from,  and  showing  no  sij,'ns  of, 

th<'  iiiHamniatory  process.     N'ery  often,  however,  we  encoiuiter  an  acute 

lirritoniti.'  of  wider  extent  which  fails  to  imi)licate  some,  it  ma.\-  be  a 

<()nsiderable,  part  of  the  cavity,  and   this  without  the  sharp  line  of 

dcniarcation  l)y  adhesions  just  noted.     There  may  be,  it  is  true,  slight 

I'orniation  of  fibrin  between  the  coils  at  the  periphery  of  the  area, 

lint  so  slijiht  as  to  make  it  evident  that  M)nie  other  factor,  such  as 

^Ta\  ity,  is  likewise  efleetive.     This  we  term  a  locally  diffuse  peritonitis. 

I'cr  example,  very  frecjuently  a  pelvic  i)eritonitis  fails  to  extend  into 

tiie  middle  area  of  the  peritoneum,  or  a  peritonitis  involving  the  small 

intestines  in  general  does  not  art'ect  the  area  oi"  the  stomach  and  spleen. 

Ill  the  production  of  such  a  restricted  inflammation,  it  is  true  that  there 

iire  certain  j)hysical  factors;  thus,  an  inflammation  may  be  largely 

restricted  to  the  lesser  peritoneal  sac,  or  may  be  bounded  by  the  meseii- 

t(T\  or  by  the  great  omentum.     The  universal  form  is  in  general  of  a 

Mippunitive  type,  the  pus  being  as  abundant  immediately  beneath  the 

tlijiphragm  and  around  the  spleen  as  in  the  peK  ic  cavity. 

As  regards  the  forms  of  peritonitis,  it  may  be  laid' down  that  what 
H  true  (»f  one  serous  sac  is  true  of  another.  We  meet,  that  is,  serous, 
serofibrinous,  hemorrhagic,  and  purulent  forms,  though  the  purulent  forms 
;irc  relatively  more  freciuent  than  in  the  other  serous  cavities.  It  is 
not  safe  to  imagine  that  these  stand  in  their  order  of  gravity,  for  the 
most  (|iii(kly  fatal  case  we  have  seen,  one  fatal  within  twelve  hours  after 
iipparentlx-  i)erfect  health,  gave  a  serous  fluid  containing  a  i)ure  culture 
"f  strei)tococci,  while  Bacillus  coli  infections  may  yield  abundant  foul 
pus  and  yet  undergo  complete  recovery.  What  is' particularly  notice- 
id)l«"  Ml  this  relationship  is  that  typhoidal  peritonitis  is  characterized 
I'v  it>  .lilliise  character,  absence  of  adhesions,  and  lack  of  i)us  cells;  the 
'hiiiger  of  such  a  diminished  reaction  as  is  seen  in  cases  of  this  nature 
IK'S  Ml  the  rai)id  difl'usi  n  of  the  irritant,  and  generalization  of  the 
pruccss.  Too  few  leukocytes  exuded  with  defective  fibrin  formation  on 
tljc  one  hand,  and  too  abundant  exudation  of  leukocytes  on  the  other, 
with  rapid  digestion  of  fibrin  as  it  is  formed,  equally  favor  a  dittuse 


564 


THE  DIGESTIVE  SYSTEAf 


W  i 


:  I     4 


as  distinct  from  a  localized  peritonitis.  A  form  of  purulent  peritoniti; 
that  deserves  mention  is  not  infrequently  seen  followiiijj  upon  laparot 
omy,  namely,  that  characterized  l»y  the  presence  (»f  one  or  more  isolatec 
pockets  of  pus  between  the  viscera.  This  occurs  chiefly  where  draina^t 
has  been  employed,  the  mere  act  of  laparotomy  having  removed  tlit 
greater  part  of  the  pus  and  thereby  having  improved  the  ability  of  tli« 
I)eritoneum  to  form  adhesions;  the  very  excellence  of  these  adhesion: 
prevents  certain  remote  infected  areas  or  ixickets  from  obtaining  frei 
drainage,  and  in  such  pockets  multiplication  of  bacteria  with  progressive 
pus  formation  may  go  on. 


Fia.  248 


Kxogenous  per"  lUou  of  thr  lower  cnil  of  the  aRcendiQK  rolon.  The  illustration,  wiiicli  ia 
natural  size,  whuvx-  wr-ll  the  i-urious  raised  and  perforate<l  condition  of  the  mucous  membrane,  wen 
from  within  the  howel,  and  at  a,  the  opening  throuish  the  musc>e  wall.     (Adami.) 


It  is  interesting  to  note  how,  in  generalized  peritonitis  as  in  generalized 
pleurisy,  the  supi)urative  i)rocess  rarely  extends  into  the  walls  of  the 
viscera  and  induces  perforation;  it  is  only  where  we  have  these  localized 
areas  of  su[)purative  peritonitis  that  the  presence  of  the  pus  upon  a 
soft  viscus  arresting  the  nutrition  of  the  walls  of  that  viscus  favors  tlie 
production  of  what  may  be  termed  exogenous  tilceration  and  perforation. 

Ktiolofiy  (if  Prritnniti.!. — As  to  the  causes  of  i)eritonitis,  these  may  l)e 
(1)  traiunatlc,  from  without;  (2)  enterogenous;  (o)  from  other  viscera 
by  extension  or  by  escape  of  contents,  p.  g.,  \n\e  and  urine;  (4)  hema- 
togenous, and  (.'))  cryptogenous. 

Of  these  the  commonest  are  those  originating  from  some  portion 


77/ A'  I'KRITOSFArSt 


665 


Fio    249 


of  t!u>  howcl,  oitluT  through  rupture  or  iwrforation  or  sec-oiidary  to 
intlimimation  of  the  saiiu-  without  actual  rupture.  It  is  u  matter  of 
i\  crx  -<lay  ohservation  that  a  peri-appeinii?itis  presents  itself  around  an 
iiitlanied  appendix,  as  if  the  peritoneum  were  preparing  itself  against 
tlif  jxtssihle  perforation.  As  to  the  bacterial  causes,  the  forms  most 
t'r(<|uently  found  are  the  H.  ooli,  streptococcus,  staphyloccK-ens,  \\. 
typhosus,  pneumococcus,  and  Ronoc»KX'us,  the  last  particularly  in 
IM'lvic  peritonitis  of  the  female.  Where  the  eontt-nts  of  the  bowel 
»seap«'  into  the  cavity,  it  is  evident  that  one  or  more  of  a  vast  numln-r 
(if  potentially  pathogenic  intestinal  bacteria  may  be  concerned.  While 
tlie  H.  coli  is  most  commonly  encoimtered,  many  observers  tcxlay 
rtpird  this  not  as  the  primary  but  as  a  secondary  pathogenic  agent. 

Chronic  Peritooitis. — Where  acute  peritonitis  undergoes  resolution 
tlicre  is  a  great  liability  for  adhesions  to  be  left  which  undergo  organiza- 
tion and  often  contracture,  and  these  may  be 
the  cause  of  grave  after-eHects,  viz.,  stricture, 
kinking,  or  internal  hernia  by  a  loop  of  bowel 
slipping  under  a  fibrous  band.  This  organiza- 
tion is  a  gradual  process,  and  what  is  more, 
the  irritation  set  up  by  displacement  and  con- 
>('{|iuiit  congestion  of  the  viscera  may  itself 
(institute  a  cause  of  continuance  of  the  pro- 
cess that  cannot  be  designated  otherwise  than 
fisa  chronic  peritonitis.  Other  forms  of  chnmic 
peritonitis  may  be  associated  with  long-con- 
timied  passive  congestion  leading  to  a  diffuse 
thickening  of  the  peritoneum.  A  remarkable 
and  extreme  form  of  this  chronic  peritonitis 
is  seen  in  the  condition  of  hyaloserositis,  or  as 
it  is  termed,  where  it  is  local  affecting  par- 
ticularly the  surface  of  the  liver,  icing  liver. 
In  tliis  condition  a  dense,  porcelain-like  de- 
posit of  hyaline  tissue  covers  the  surface  of 
tlic  liver  and  spleen  and  is  accompanied  by  a 
thickciung  and  contraction  of  the  great  omen- 
tum, leading  to  the  formation  of  a  thick  hyaline 
mass  lying  along  the  transverse  colon.  More 
rarely  the  same  condition  is  seen  in  the  ileo- 
cecal region.  Its  exact  causation  is  still  un- 
determined,  but  in  a   certain  proportion  of 

cases  it  is  associated  with  a  very  chronic  form  of  tuberculosis,  and 
occasional  caseous  areas  may  be  detected  in  the  deposit.  Coincidently, 
tlic  pleune  and  pericardium  are  apt  to  present  a  similar  condition. 
Aicouipanyiiig  this  lesion,  there  is  ascites. 

Tuberculosis. — This  is  relatively  common,  and  while  at  times  it  is 
'Iry,  it  is  generally  accompanietl  by  a  low  form  of  serous  peritonitis. 
Broadly  two  forms  may  be  recognized:  one  in  which  the  infection  of 


Hyaloaeroaitia  of  spleen;  sec- 
tion tbrough  spleen  showing  at 
a  sn  area  of  hyal.>sero9itis  of  cap- 
sule; h,  splenic  tissue.  (McOill 
Path.  Mus.) 


:m 


Til!-:  bUlESTlVK  SYSTEM 


J.  ,r„„,,,,  ,.r  „ ,,,,, ,  i,,„i,i I,,  i,„„ , „ ,:.'   1 :  t,',  J 

I.    I.:..,ll,  „v,.r ,  „.  s„rr„„. „r ,l„. |..,i„„„.,„„;  ,1  „, i,  „  „ ,     "™    ' 
...«.>  ,.r.  „.s,,„l,l,„B  „  |„„„|l,.|  »,.,!,., „ I  ,„  „„.  ,,|,4t,      ' ,", ,  ,"1 : 

'•t  thr  s..r..,is  surfa(v  of  neiKl.l..M-in;  ..oils  of  tin-  how        "',''•""",: '."'^ 

ChiU  ;"""       ""  ",•''*•■"  ''"'■  *"  '"'rtal  cirrhosis  of  tlu-  liv" 

Actmomycods.-  Actinomycosis  is  Iial,le  to  involve  the  noritonc-  -n 
MVonWary  to  its  presence  in  the  appendix  or  other  r  -.i  .„  ,.  t  e  "  w*.  ' 
It  nmy  lea.    to  fistnhe  thru„,.h  the  ah.h.n.inal  wall  '' 

iifimi  oil  ,111(1  iH'  iree  in  tlie  r'jivitx-   -ic  t^l..^-  ..i  .. 

T..o..^.  rupture  of  the  ^Nhh:!^;;' or ';•  i^l.r^Kr  t^lf'S 

Entire!  M    !?"•'""•■  ^'^''  "'^""•'■^  ^  "'">■  '•'•-  the  t^^     o 
c  .  ;r  '■•V'"'">'^'^*"^'""-  t'H-  fa-tus  inav  esc.ipe  into    he 

h o^on  tXs'   •  'h '"'^*"7  ^■"''•'«"'^^-"  -lithopedion);  iJattemp!;; 
a.xrtion.  needles  or  other  instruments  ii,a\   perforate  the  uterine  w, II 
an.  -..pe  into  the  unity  =  while  Hurin,  laparotom  v,  Uges  a  n    L^ 
"H-nts  have  been  ina.Ivertentlv.  an.l  happily  rarelV.  ^lit.w^l  io  r;;„S;, 


in   the  cavitv. 


In   perforation  ..f   the   intestines.,  hesides   the 


|„,u,.|  .    ,  ,      ,       •  -   ■-\--'  """"  "■■    '"'■   iniesiines..  riesides   the  nMni!,il 

i;:;;l.;r;::;i;:,;;::':!,'"""  '-'>  "'■"-••■"'"■>  '■'•  '■■■ -» i--. 


Twr '••■»»• 


TIIF.   I'HUITnSErM 


507 


Fia.  2J0 


Regressive  Changes. --Uc>Krcssiv«>  clumm-s  in  tlu>  iMTitoiicuni  are 
iii((iii>i<l«'riii)l«'.  ()<<!i^i«>iuilly  \\v  ciiciiiiiitt-r  lu'crusis  with  licinorriiiiKt* 
(if  III)  iiKliviiiiiiil  appniilix  i'|)ij)|oi(ii  tliri»ii);li  torsion  of  its  iHtliincle. 
Necrosis  of  the  iicritont'Mm  ami  snhixritoni'al  fat  o<cnrs  through  the 
.!( tion  of  cscaiM-d  pancrfutic  srcrction.  Small  an-as  of  pigmenUtioa 
:irc  occasionally  ohscrvcil,  particularly  in  the  |H'lvic  region,  possihly 
-rcondary  to  ccchyinoscs,  although  they  a;)p«-ar  to  hear  soni«'  relation- 
ship to  ehrom  constipation;  I)Io(hI 
pi^imeiit  ma.  he  oi)serveil  loii^; 
lifter  a  lienionhaK'e  has  heen  al)- 
>iirhe(l. 

Progressive  Changes.  -  What 
MiMie  authorities  term  fibromas,  seen 
nil  the  surface  of  the  >ple«'n  in  elder- 
ly individuals  in  the  form  of  one  or 
more  flattened,  tal!o\v-like  projec- 
tions, are  not  hlastoinatous  hut  are 
allied  to  hyaloserositis.  Of  the 
[KTitonenm  proper,  namely,  theen- 
ijothelial  memhrane,  there  is  hut 
one  new  growth,  the  endothelioma, 
which  at  times  closely  resemhies 
liircinoma  in  the  {inger-like  pro- 
cesses that  invaile  the  underlying 
ti>sues.  From  the  suljperitoneal  tis- 
-Mcs,  a  series  of  connective-tissue 
tumors  may  develop,  lipoma,  lipo- 

chondroma,  lipoma  myzomatodes,  fibroma,  angioma,  and  sarcoma.  Thes<- 
ire  particularly  liahle  to  grow  in  the  root  of  the  mesentery  and  in  the  retro- 
lieritoneal  fat;  especially  in  the  fat  overlying  the  k'dneys  are  we  liahle 
tn  meet  lipomatoid  overgrowths  and  the  pnuluction  of  massive  tumors 
wliich  may  show  tuyxomatons,  chondn  natous,  osteomatous,  and  sarco- 
matous areas.     Teratomas  oirasionally  envelop  suhperitoneally. 

Secondary  tumors  are  apt  to  involve  the  peritoneum  hy  extension; 
tliiis  fie  j^reat  omentum  may  he  the  seat  of  extensive  carcinomatous 
irrinvtl  ~  "n  cases  of  carcinoma  of  the  stomach,  pi,-  reas,  gall-bladder, 
'ir  (lu'is,  and  where  there  is  colloid  cancer  of  the  rectum  this  sprea<ls 
I'xtt  -iively  ah)ng  the  peritomuni.  Other  secondary  growths,  notably 
cystadenomas  of  the  ovary,  grow  hy  implantation,  the  rupture  of  one 
"I  the  ovarian  cysts  liberating  cells  which  may  seed  themselves  upon 
the  iKTitoneal  surface,  giving  origin  to  very  nmnerous  small  tumors. 
\\e  liave  seen  a  similar  <liH'use  impliintation  of  lymphosarcoma  over  a 
l;irge  area  of  t\\v  jH'ritoneum  (Fig.  71,  p.  21S),  which  is  'so  a  favorite 
-itc  for  secondary  melanotic  growths. 

\;irioMs  orders  of  cysts  may  present  themselves  in  /onnectiun  v.itl 
tlie  peritoneum.  As  already  noted,  persistence  of  the  median  portion 
"I   the  omjihalomeseraic  duct  gives  origin  to  a  vltello-intestinal  cyst. 


Fat  iM'(T(wis  of  appendiccii  epiplnics,  from  a 
ni,-*,'  of  piiDcrcatit'  n(?cro«i8  ("beinorrhiigic  pan- 
(■rrutitiM"j:  'I,  while  ureas  of  fat  necroiiis;  b. 
rolou.     (McUill  Path.  Mu9.) 


^'UNSir  : 


508 


THE  niGKSriVE  SYSTEM 


III  i 


niay  be  encountered, .  ue  to  ruS-      .       "^^'^,^"  ctks.    Parasitic  cyits 
of  a  hycJatid  of  the  liver.        ^  '^"'"  "'  *''«  ^""*«"ts  i"  '■•moval 

HERNIA 

a  secondary  sense  the  tmn  i^  .L  .'"^T""'  "'  ^^^^  l«"«^tes.     In 

whichapor^ionof  thea  .dm  ...f^L:^"'^^^  *"  '"'.''"'^  '"■"^'t'"-  "> 
but  through  openings  i,]  t  ^on  e  t  ,n  I'T'  ""*  *'";""«^  *''^  P^^^^tes 
peritoneal  pockets.^  VVe  t  a,  n  .k  •,  I  I'  T-""7'  "^  ^^''"^'«^^'  "••  "'to 
the  external,  and  the  latter     he  i^temll  •''''"   '"V^^^™  *''«  ^^'^^r, 

oocur  in  regions  of  «.  "i/ital^^  fl™f  ^  ^  Tf''  P'-^t'-"-^''^"  •"«>' 

the  inguinal  or  femora    «.        the  2  .r  .     'I  '>'"'"™i"«I  wall,  as  at 
<T.  again,  in  regions  of  »;      td  we  t  ''"u'''"'  '^'  "^^ilicus, 

laparotomy  scars,  and  if        ni  hH  V'".  '"  *^'  "'"'Rhborhood  of 

through  pregnancy  or  other  Si  u,'  "'""^'  "r'  "'"'»''^"^'  ^^hen 
the  recti  muscles  h  enlarged      \  V  k  ^T"'  ^'Y  '^""^'^    ''^'^ween 

consequent  giying-way  wi,';  to  in  T  *'"  '''"'""""al  "all.  with 
in  the  proclSctioJ  o  th"  't  ,  'rr  •'"'^^T- '.  '^  /''^'  P""»'  *■-■*- 
«ac  is  forn,ed,  line,!  by    I'e  par  '    l '  ^-^  ^^  "'  .*'"-^  Saving-way  a 

"lay  pass  various  visceraTcco  i  *,'  "*""V'""-  ">"l  >"to  that  sar-  tlicre 
coils  of  the  small  intt^th  e     v      ^     \       "*""*'''"  "*  *''«  ««^''  viz..  the 

or  other  portion  .t.twg"  , win  ""'7'"""'  ^"'""^  '''"''  ^PP-««-^ 
or  portion  of  the  stoma  W     ri^'^T;   "'-^'/arely  ovary,  spleen. 

enlarges  it  is  apt  to  expand-,       in  th  ''"'.■'■''  '*'•    '^^  *''^  ^»'^ 

narrow  neck  w  th  a  more  ,''"*'"' ;'"-\*r  '^'"'""*  ^  ''^''■'t'vclv 
patency  of  the  sic  nv^v  n  ''!"""""" V^*''"-''''"'""'"^'  cavity.  This 
the  sac  may  oc^r  ;^:'t;ir/'r^".'r'"''"  "^  *'-  -"tent  o 
expans.on  of  the  conlJn';  '  rUwelT^he^""*^-  ^"^  >''^«"^'' 
be  set  up  with  resultant  aclhesi^.n  o  t  '  tr.  k' TTl'""  '""•^■ 
Passmg  „,  may  oppose  return      It  is  in  tl  '■  .•^""'  ""^  *''^  t'''*^"^ 

imminent  danirer    with    s  - 1 '  ,  "  "  '"  ^''^^^^  conditions  that  there  is 

ofthenec.k:Sur    ,eTree*?rrror.    *'"'    '^'^    ^'^"^*-^'«" 
mass  becomes  larger  throne'  this  nl?      ?•   T'  '''"'"'•     The  hernial 
more  pronounced'  L    TLl    ,Z'T  l'""'  *'''  ^'"'.-triction.  therefore, 
ending  in  stasis.  I  .ids  to  necrts  s 'n  I  •"''"■«™''^^"/  !^  tbe  result  which 
and  these,  whem-ver  a    •  por     ^        l^'l '"'T  "^  '^''-  ''^''•"'«'  ^""t"'^^' 

cerned,  eventually  bec.>n,c Wt   1    i  ,"''  ^""taming  feces  is  con- 

1.  External  HerniaT  V      »  1        *  """'  gangrenous. 

inguinal  H^^a       rn-;n  ttis  ;;'';r'"^'  '"'"-^  '"«  *°  ^e  recognized: 

?cen  in  woman.     It   s  Z  to  u.i^^u    0^""'"''"''*  ^r''  '"'^  '*  '''  *»'- 
n  the  region  of  the  ing  h,  d  "    '  '  'Tin'.'"' • ""  '''"''"^"'  "^  *^^  *'=^«"- 

inguinal  canal  itself  fobUque  i^i^.,  J ''".\^ '^"T'"  "'"•''  P''^^''  ''"^^n  the 


HERKlA~rHE  LIVER 


nm 


.leveloped  what  is  known  as  direct  inguinal  hernia,  ..riKinatinR  internally 
o  the  inner  side  c.f  the  internal  orifice  of  the  canal  hut  present^n/hself 
through  the  external  ring.     Either  of  these  forms  mLv  nw  extern 
.l.nvn  the  scrotum  to  form  a  scrotal  hernia.     If  the  hernia  \,es  no 

in^Sl  iZ'  *'"  "*^'"'"'  ""^  ''^  '^'-^  "•^«*  '^  ^"-"  -  ^-»Ple^ 

2.  Femoral  Hemia.—This  is  more  common  in  woman,  the  channel 

.nng  formed  along  the  course  of  the  femoral  vessels  ^nd  so  be"  w 

I  -'P«rts  ligament  and  along  the  tipper  part  of  Hunter's  canal 

.Mnl.iKwn;  Hemia.-Abdominal  contents  may  protrude  through  the 

ihcal  ring.     This  may  he  congenital  hut  it  is  most  often  seen  in  the 

nu  Itiparous  female;  the  sac  may  attain  great  size.     Somewhat  smila^ 

heir*  H"*  ?^^r"^  ''''"^'•*^^  ""^^' '"  '^'  ""''"«  'in-  i«  the  abdoSna 

the  resul    of  a    aparotomy  in  the  me.lia„  line.    Epigastric  abdo^l 
hernia  m  the  middle  line  ahove  the  navel  is  rare  aoaominal 

4.  Other  Forms.-Other  forms  are  also  rare,  viz.,  obturator  hernia 

Zal  tLtirtri  ^•"•r-'"l --««''  *»--«•>  tl.  s'acroscllulc  no™; 
permeal  thro  igl  the  levator  am;  vaginal,  through  the  giving  wav  of  the 
uall  of  Douglas  pouch.     Diaphragmatic  hernia  ma v  he  .lue  either  t-! 

;hCh';^umat!r  ^Xr"'^^'"^  "^  *''"'™^= ^^^  -^  ^'->-  ^^ ««»--' 

fiitemal  Hernias.-Internai  hernias  show  no  protrusion  through  the 
^>  ..lonimal  parietes;  they  are  relatively  infrequent.  Through  upture 
.;r  imperfect  formation  of  the  mesentery  oeeasionallv  the  abdom  "J 

tt  fntosn'"'  '"''''^''"'Ti  -f  -  J-.-,  if  not  the  greater,  p7  ion 
't  the  intestine   may  pass  behind  some  part  of  the  peritoneum-  or 

Vn  iowT;;^.^r'"''?^rr^  '^^  ^'"^^•"'  through  \he  foZen  S 

>N  nisloH   to  the  filling  of  the  lesser  omental  sac.    The  fossa  duodenalis 

.ay  further  give  way ;  similarly  the  subcecal  and  intersigmo  1 1  "1  ^ay 

iorm  sacs  containing  hernial  masses  of  the  intestine.  ^ 


THE  LIVER 

Simple  as  is  the  structure  of  the  liver,  there  is  no  organ  in  the  bodv 
'^^  Inch  more  various  metabolic  activities  have  been  j.^tlv  attribute, 
y^reat  importance  is  in.licated  by  its  size  (14()0  to  ir,(K    gram'  ) 

n    •  I  ••    ^  ■'^^If.'-«t«>n  "f  the  iron  <.f  the  hemoglobin  from  the  dis 

;  SSt^ri'n-'d  r  "r  .?'^"7^=  *•"  ^"^^•''"^*''^  "^  '•-  buerits  nd 

i      emr      t        Tv*"   ?"  "^  *'!"  '"^^'•'""  ^"P^^''^'  °*"  ^^e  blood  and  tissues 

e''ci  culat^l  fS  •^^^'•r^'^"'^  "^'^ivities:  the  regulation  similarlv,  of 

■     to  .of  n^     <■'  ""^  f^'Y^^  the  same  and  other  lipoids:  the  for- 

•'•'t.on  of  urea.    Sjtuai.d  at  the  head  of  the  portal  system,  which  brings 


570 


THE  DIGESTIVE  SYSTEM 


i' 


to  ittlu- various  s..l,staiKrs;,l,s„rlH'.l  from  tin-  walls  of  the  intostine  the 

CT  acts  as  a  protec-t.ve  or^an.  arresting  an.l  excrotin,.  or    S   .^h^ 

t oxK-  f,o<lu.s  „t  various  onlt-rs,  and  in  this  way  acnnnulatiuK  "^rtah; 

o  sous  su,  1.  as  arsnuc-  au,I  phosphorus.     As  with  the  organs    '.i, era 
althouKh  ca,.al.le  o  w.thstaudiuj;  the  iusults  of  partieuhir  (,r.  ers  n  nar 

Kuh.r  decrees,  au.l  although  iuteu.led  for  sueh  a  purpV^     uev'r    ^^^^^ 

r;;.fn  t  "'  tt  '"  '^^'T'  "••'  ^''^  "^•^■'- «' -y  tl.erel,^■  sX ; 

S  therefore,  the  seat  ot  ma..>-  u.flamniatory  and  deK^nerativ^  processes 
^lm•h,  m  tnue,  uiterfere  with  its  prime  nu.tah,.lic  purpo  ^s  Crthe 
ar-reac.lunguuport.„Ke  of  pathological  change  in  itlstncture '^  1  ^ 
rofoun.l  general  d,sturhau<-es  to  which  .lisease  of  this  vise      urn  gve 

S-h  f ";  'f 't  "'"'  """^'"•"'''  '"•'•^'  ^'"*''''  i"t<' the  minute  aSomv 
^^\wh  should  he  known  to  every  student  of  histologv      \t  m,^t    L 

may  nra  1  that  it  is  ahun.lantly  vascular,  so  vascular  as  m  hf.  lie    n 

contau,  the  whole  Mood  supply  of  the  body;  that  i      a    a  1  ouble  1„ 

upply,  system.c  and  arterial  through  tlu-  hepatic  artev         ta  t 

enous  through  the  portal  v,  in;  that  the  entering  '.ood  rS'  *  he 

nd.vulua    lobules  from  their  periphery  to  be  colk'te,!  iutc   a  m  tra 

mtralobular  branch  o   the  hepatic,  vein,  whic.h  carries  it  to  tlu-   SS 

N.-na   cava      Toutranwise,  the  bile  capillaries  pass  ou twanl     o  the 

periphery  o    the  h.bule.  there  joining  to  form  the'  bile  diSs   and  thus 

aspect,  to  a  bloc^d  capillary  or  sinusoid  and,  on  another,  to  a  bile  canillarv 
1  here  is,  uidee.  ,  evidence  that  within  the  individual  ive  c^H  t  e  e  a  e 
fine  channels  intimately  connected  with  both  s^•stems 

Abnormalities.-The  abnormalities  of  the  "liver,  as  comoared  wiH, 
other  organs  of  the  body,  are  distinctiv  few.     It  mav  show  consoler 

"nmcl  of  in  t  ''''  '""•  ■  ''7?  «T^  '<">««.  i»  fjeneral  small,  or  masse  , 
snared  ott   in  the  course  ot  developme.  \  mav  lie  in  the  neiirhb..r 
hood  of  the  mam  organ,  ..  g.,  i„  the  suspensor;-  ligament  or  !he  m^t 
omentum.     Liebermeister's  grooves,  cleprc^ssionsVun'rg   n  the  anSro 
P|.ster,..  direction,  while  most  often  acquired,  may  b'e  coi  genS      i 

i    pc>rt    ,.1     •  of'ST'l-     .  '■  ''"''■'"  ""  '"^'^'"'"^  <l-elopment  or  an 
mptrtroph>    of  the-  diaphragmatic   musculature,  the  grooves  corre 

i-nti:";' ^[^I'lrtur  ""*'^  ""  ""  ""'^•'  •"  ^^'"^'^  *»--  ^as  bee,. 
a.;;^rL^&na.SJ 

X  c  St    c      h  :  1     "  ••^''•"'"•""'■'ts  of  the  climate.     In  infective  and 
mcnt  of  acTue  congestion.     In  temperate  zones,  passive  congestion 


THE  LI  V Eli 


571 


p  niufl,  more  (•<.n.,n....ly  .-noounterefl  as  a  result  ..f  clironit-  obstructive 
heart  or  hver  . hsease.  'H.e  orf;an  is  enlarged,  tense,  its  e<iges  more 
tl.an  ..sually  ol.tuse,  its  color  from  a  chocolate  brown  to  a  dark  purple- 


Fid.  251 


Fiu.  252 


^n 


im. 


NutnieK  liver,  showing  n  small 
i(!i,  luiiural  siip.  of  the  cut  eiir- 
"'■      (MrGill  Path.  Mua  ) 


Fig.  253 


Earl.v  stage  of  passive  congestion  of  liver  from  ne.r 
centre  of  lohulo,  showing  „,  liver  cells,  somewhat  shrunken- 
6.  wall  of  capillar)-,  separate,!  from  liver  cclU  by  cedemal 
<j>u..fJu.d;  c.  pigment    from   destroyed  red  blood  corpua- 

f  ?.h        /TT'"'  ''"'■"  ''""'  '*"  ""'  of  the  drawing 
lor  the  sake  of  clearness. 


Fia.  254 


Later  stage  of  the  mmp-  a,  red  blood  cor- 
l>usr|„,  which  have  escaped  into  the  space 
previously  occupied  by  the  liver  cells;  h.  greatly 
-shrunken  and  degenerateil  liver  cells.  The 
:nus„i,i.,  Miu  even  more  dilated  than  in  the 
earlier  stage.     (After  Mollory.) 


Still  later  stage  of  the  same  condition.  Here 
the  cells  of  the  mid-.one  of  the  lobule  have 
completely  dis«ppeare<l.  their  place  being  taken 
,  -i...'i\a..ii.'<i  t...^\  .  •jrpu.-!cic3  t,h) ;  ,j,  reiiittiu- 
ing  cells  of  the  peripheral  tone  of  the  lobule; 
c,  cell,  of  inner  lone  showing  abundant  fatty 
vacuoles.    (After  Mallory.) 


o/: 


THE  DIGESTIVE  SYSTEM 


.  1;! 


Fia.  255 


often,  aljo,  with  enlargement  of  the  right  side  of  the  heart  and  of  tl 
liver,  there  is  to  be  noted  a  distinct  hoUowing  of  the  upper  aspect  ( 
the  left  lobe — a  cardiac  gulf  or  groove.  Where  the  condition  has  bee 
long  continued,  the  surface  is  apt  to  be  obscurely  granular,  due  to  tl 
fibrosis  which  inevitably  follows  long-continued  moderate  congestioi 
On  section  of  a  moderately  early  case  the  appearance  is  characteristi 
and  gives  the  name  "nutmeg  liver"  to  this  condition;  the  centres  ( 
the  lobules  are  dark  retl  from  congestion,  a  congestion  so  extreme  tht 
the  cells  of  the  central  zone  of  the  lobule  undergo  atrophy;  owing  t 
the  obstruction  to  the  circulation,  the  fat  brought  by  the  portal  bloo 
is  not  actively  consumed  and  is  stored  up  in  the  remaining  periphen 
part  of  the  lobule,  the  light  color  of  which  contrasts  strongly  with  th 
red  or  brown  centre;  the  cut  surface  of  the  liver  tissue  resembles  ver 

closely  the  grated  surface  of  tli 
nutmeg  of  domesticity.  As  th 
congestion  continues,  both  th 
lack  of  nourishment,  owing  t 
the  slowed  circulation,  and  th 
increased  venous  pressure  lea 
to  an  extending  atrophy  of  th 
cells  of  the  centres  of  the  lobule 
and  with  this  there  is  some  in 
crease  of  the  connective  tissu 
around  the  central  vein;  with  th 
continued  malnutrition  of  th 
peripheral  cells  less  fat  is  store( 
up,  the  whole  organ  thus  assum 
ing  a  darker  color  with  somi 
shrinkage  and  increased  firmnes 
— cyanotic  indoration.  Congestioi 
secondary  to  thrombosis  of  thi 
hepatic  vein  or  its  obliteratioi 
is  rare. 

Infarcts  of  the  liver  are  of  two  kinds,  the  anemic  or  white,  and  tht 
red.  These  have  a  different  origin;  the  white  infarct  is  brought  about 
by  embolic  or  other  closure  of  a  branch  of  the  hepatic  artery.  Despite 
the  relatively  small  size  of  the  hepatic  artery  as  compared  with  the 
portal  vein,  it,  experimental  closure  leads  to  a  necrosis  of  the  organ  or, 
stated  otherwise,  arterial  blood  is  necessary  for  the  perfect  nutrition 
of  the  liver.  Thus,  despite  continued  portal  circulation,  if  a  branch  ol 
the  hepatic  artery  be  obliterated,  especially  where  there  is  already  an 
ivipaired  general  circulation,  the  local  area  of  sunply  undergoes  necrosis, 
Ijecomes  pale,  and  shows  typical  white  infarct  "formation.  Red  infarct 
is  the  result  of  closure  by  embolism  or  thrombosis  of  a  branch  of  the 
portal  vein.  The  appearance  obtained  is  that  of  a  sharply  defined, 
more  or  less  wedge-shaped  area  nf  darker  red  color  stand=ig  out  in 
sharp  contrast  to  the  paler  brown  liver  tissue.     If  necrosis  be  taken 


Red  infarct  of  liver.  Section  of  the  organ 
(less  than  the  natural  siie).  so  cut  as  to  ex- 
pose two  branches  of  the  portal  vein  into 
which  extends  a  thrombus  (6) ;  o,  area  of  red 
infarc',.     (McGill  Path,  Musj 


THE  LIVER 


573 


as  the  essential  property  of  an  infarct,  this  is  no  true  infarct.  Sections 
studied  under  the  microscope  show  the  cells  still  intact  with  well- 
staining  nuclei,  but  each  column  of  liver  cells  is  surrounded  by  intensely 
dilated  and  congested  sinusoids  or  capillaries.  The  condition,  however, 
may  be  compared  with  the  red  infarct  of  the  lung,  where  similarly  there 
is  a  double  circulation,  and  where  closure  of  a  branch  of  the  pulmonary 
artery  is  followed  by  an  intense  congestion  without  necrosis  of  the 
involved  tissue.  The  liver  is  a  favorite  site  for  minute  cell  emboli, 
either  those  derived  from  the  placenta,  or  in  rarer  cases  from  the  bone 
marrow,  or  from  peritoneal  or  other  fat  cells  after  operation,  or  from 
coiiglutinated  erythrocytes.    They  cause  focal  necroses. 

Thrombosis  of  the  main  trunk  of  the  portal  vein,  again  resembling 
that  of  the  main  pulmonary  artery,  is  unaccompanied  by  this  infarct 
formation  or  by  any  marked  change  in  the  liver  tissue,  save  when  the 
thrombosis  is  of  infective  nature.  Thrombosis  of  this  vein  is  not 
uncommon,  and  may  be  brought  about  in  more  than  one  way.  The 
commonest  cause  is  by  extension  of  thrombosis  or  thrombophlebitis 
iti  one  of  the  mesenteric  or  other  branches  of  the  portal  vein,  from  an 
area  of  iiillammation  or  an  operative  lesion;  or  inflammation  within 
the  liver,  by  affecting  the  wall  of  one  of  the  larger  branches  may  cause 
a  localized  thrombosis  within  it,  which  may  extend  and  involve  still 
larger  branches. 

HemorThage  is  most  commonly  traumatic,  but  small  hemorrhages 
may  occur  around  actively  growing  tumors,  in  the  neighborhood  of 
abscesses,  in  cases  of  the  so-called  hemorrhagic  diseases,  in  eclampsia, 
and  in  "acute  yellow  atrophy." 

A  condition  not  often  recognized  is  that  of  oedema  of  the  liver.  Our 
attention  was  first  drawn  to  this  in  the  routine  insertion  of  pipettes 
to  obtain  liver  juice  for  bacteriological  purposes,  when  not  infrequently 
we  obtained  a  fluid  that  was  thin  and  evidently  a  mixture  of  serum  with 
l)I()o(l.  Microscopic  section  of  livers  affording  such  fluid  presents  a 
( liaracteristic  picture.  The  columns  of  liver  cells  appear  shrunken  and 
widely  .separated,  and  on  examining  the  space  between  the  columns 
tlic  capillary  channels  are  seen  separated  from  the  liver  cells  by  clear 
spaces,  evidently  containing  serous  fluid  (see  Fig.  2c1 ).  In  some  cases, 
tlie  accompanying  atrophy  of  the  liver  cells  appears  to  be  primary,  in 
w  liich  case  the  oedema  is  evidently  ex  vacuo. 

Inflammation.— Acute  Hepatitis.— It  is  perhaps  difl^cult  to  make 
anything  like  a  sharp  line  of  demarcation  between  the  active  physio- 
logical hyi)eremia  to  which  we  have  already  referred  and  what  is  known 
as  acute  hepatitis.  In  both  conditions  the  organ  is  enlarged  and  hyper- 
ctnic,  hut  where  toxic  agents  such  as  the  toxins  of  acute  infections  and 
I irtain  mineral  poisons,  etc.,  or  again  the  products  of  abnormal  diges- 
tion are  brought  to  the  organ,  it  is  common  to  find  cellular  changes  in 
addition  to  the  hyperemia,  and  it  is  this  cloudy,  passing  on  to  fatty, 
;i<f;(iuTation  that  is  regar^  -^  as  the  distinguishing  feature  o.'  general 
iiillammation  of  the  org  .».    '  c  severer  car-,  there  is  in  addition 


mi-i  ■      * 

Irtr   1 


574 


TIIK  Did  EST  I VK  SYSTEM 


»tn,|,l,.v  r,  l,c.|,l  ,„  „r..„.,l,.  „„,  ,„„„  „,  ,,„,„„,,  „,  ,,,„;Vt;;,;i,t 

Fia.  25(1 


by  ,he  ab»,.os..:  ,/,  ,.,„„pros»,.,l  v,",»  "'-nbrano;  .,  surroumling  liver  coila  co.npn.^.<l 

IM  a.I.liti,.n  t.,  tl.is  s.,.call,..l  simpl.  .lifh.s,.  hepatitis  we  not  infre- 

c   •■.,,/;■' tT''"'r  *'"  '■•■"^'■'■."^' "  """"  "'•^'■*-'  "'"« these  mav  t 
Tstd  H;  :  'liL-'"  f""?  *'f  ^''*i^  "'••"^'  the  curse  .,f  a  group  of 

.Vurn  u    1      '.est.';.  ."■'"?  "  '^'"""  '^'■"""^  ^PylepWebitic  abscesses^. 
urrou.Hlui^  th(  .se  ti,ere  ,s  uitense  eonge.st.on  of  the  hepatic  parenehv.na 


.M"^,«t- 


CIRRHOSIS  OF  THE  LIVER 


ntii 


IJiit,  similarly,  an  acute  asfending  infection  along  the  intrahepatic 
l)ile  ducts,  secondary  i)ften  to  suppurative  cholecystitis,  may  lead  to  a 
\  erv  similar  appearance,  though  here  the  angry  and  somewhat  dilated 
iipiH-arance  of  the  larger  bile  ducts  and  the  presence  of  j)us  within  them 
U'i\ IS  a  clue  to  the  origin  of  the  abscesses. 

The  large  tropical  abscess,  or  abscesses  of  the  liver  have  a  wholly 
-lifferent  origin.  These  are  found  most  often  in  the  di)me  of  the 
liver  and  may  be  several  inches  in  diameter.  They  contain  a  thick, 
l)rokeii-down  fluid  material  the  color  of  chocolat  ail  lait,  composed  of 
necrotic  liver  tissue  with  miMlerately  abundant  leukocytes;  they  have 

inewhat  ragged  boundaries  formed  of  necrosing  liver  tissue,  and  with 
their  extension  may  rupture  through  the  diaphragm  into  the  lung 
tissue  or  bronchi,  or,  again,  into  the  peritoneal  cavity.  These  are 
amoebic  abscesses,  and  are  secondary  to  amo'bic  colitis  (dysentery). 
Careful  examination  of  the  boundary  tissue  of  these  abscesses  reveals 
filmiidant  entama'lm\  which,  according  to  our  experience  may  be  found 
still  active  and  motile  on  a  warm  stage  twelve  hours  and  more  after 
the  death  of  the  subject.  How  these  entamopl)ap  gain  entrance  to  the 
liver  is  perhaps  debatable;  the  central  position  of  the  abscess  suggests 
tliat  they  have  gained  entrance  by  the  portal  blood. 

Chronic  Mammation.— Cinhoses  and  Specific  Inflammations.— By  the 
term  cirrhosis  we  imply  a  diffuse  extensive  laying-down  of  fibrous  tissue 
within  the  liver.  Saying  this,  it  will  be  seen  that  anatomically  such 
(lil)osit  of  fibrous  tissue  may  have  various  origins.  It  may  originate 
aroimd  the  branches  of  the  i)ortal  vein  or  may  be  of  the  nature  of 
ii  chronic  periarteritis  around  the  branches  of  "the  hepatic  artery;  it 
may  show  itself  particularly  in  connection  with  the  intralobular  branches 
(if  the  hepatic  vein  or  be  secondary  to  an  inflammation  and  irritation  of 
the  bile  ducts.  It  may  l)e  an  extension  inward  of  a  chronic  inflamma- 
tion affecting  (ilisson's  capsule,  or  lastly,  as  in  syphilis  and  tuberculosis, 
It  may  be  the  outcome  of  focal  specific  tubercular  changes  so  abundant 
as  to  be  generalized.  Anatomically,  therefore,  we  may  expect  to  find 
niinitrous  types  of  cirrhosis;  as  a  matter  of  fact  the  "arterial  form  is 
.ihiK.st  unknown,  that  in  connection  with  the  hepatic  veins,  while  seen 
III  chronic  congestion,  is  but  of  slight  degree,  and  that  following  a 
jliroiiic  niflammation  of  the  capsule  is  also  so  rare  as  to  be  negligible. 
I'lic  important  forms  to  recognize  are  the  portal,  the  biliary,  and  the 
diffuse  syphilitic. 

Laennec's  Cirrhosis  or  Portal  Cinhosis  (inaccurately  termed  atrophic 
'irrhosis).— This  is  the  commonest  type  of  cirrhotic  change.  It  is 
t"iiii(i  frequently  in  those  addicted  to  alcohol,  hence  the  term  gin- 
drinker's  liver,  but  may  occur  among  native  Hindoos  and  children 
"liu  have  never  kn(»wn  spirituous  liquor.  Clinically  it  is  characterized 
'•>  dyspepsia  and  anorexia,  ascites  more  freciueiitly  than  jaundice, 
ITogressive  emaciation  anfl  weakness,  a  slight  grade  "of  anemia,  a  fair 
'  nliirgenient  of  the  spleen,  and  death  either  from  intercurrent  tubercu- 
l">is  or  niflammation  of  the  lungs,  or  sometimes  (esophageal  hemorrhage. 


."6 


THE  DIGESTIVE  SYSTEM 


^2r^  '  '"."I'"  "'  *^t  '"•'""''■  '"^  "'"'P-'i^^^-'l  ^-arl  V.  the  liver  is  foun, 
Kreatly  enlarge.!.  I.ut  in  the  c„urse  ,.f  nu.nths  it  is  at  t  t..  u  Jem  Z 
«ressu-e  shnnkage  until  in  a  certain  pn,,„rtic,n  of  ...  es  t  is    e7y  n  ud 


Fio,  257 


Flo    2.JS 


'mm^- 


Portal  oirrhiisi»  of  the  livpr-    n  rf'    i...„i»     j  m 
The  cli,ti„,,i„n  ^etwee^the    •;ffe?;mYb       ,'1     rh''"  T'"    '"'"""'"'  """"^^  '"    '""*■  "—••"»- 
lost.     (Green  )  "  ''""'"  ""''  ""-  ^'"'"""'^  »"»nge.„en,s  of  the  ,eil»  i»  entirely 

smaller  than  normal.     AcecrdinK  to  our  experience,  in  general  the  liver 
t    .^  e.,u.i,tu.n  IS  larger  and  heavier  than  normal.     The  main  features 

<>»   the  or.an  at   autopsy  are  the  notlular  surfac-e  (hobnail  Uve^rth^ 

extreme  firmness  on  section,  due  to  the 
uicreased  fibrosis,   and   usuallv  the   dis- 
tmctly  yellow  color  t.f  the  cut\)rKan.     It 
ras  this  last  feature  that  primarilv  save 
the  luime  (^v/uir,  yellow)  to  the  condition, 
althoujih  by   association    we    now   api)ly 
this   term    to   any    condition   of  diffusV 
fibrosis.    f)n  inspectit.n  t.f   the  cut  sur- 
face the  li\er  [)arenc-h\nia   is  seen  to  be 
separated  ofl'  i„t„  small  islands  or  irrcj;- 
ular   lobules    by   bands  of  fibrous  tissue. 
I  nder   the   microscope  in    tvpical   casts 
but  irrcLnd-.r  b-..,!      (    .  uf  "  •'.""•''^tiTi^tic  is  that  the  broa-l 

lese  hnds  t  'l  ''"'  ^'''■""'  ''"^•'^'  '•"''  '^^'^^y  ^'^fi"*"^  '"'-..m 
fo  med  2 les  7"';r''-^'"«'  ""^  ••».'-^ these  islan.ls  seen  to  be  wci!- 
tormtd  lobules.    On  the  contrary,  individual   islands  appear  to  be 


llcjl)naile,l    liver    with    small    hob- 
nails,   natural    size.       (MeGill    Path 

Mus.) 


CIRRHOSIS  OF  THE  LIVER 


577 


turino(l  of  clusters  of  several  im|)erfect  lobules  (imperfe<-t  because 
th.ir  nuralobular  veuis  are  not,  in  Kcnerai,  central).  It  is  this 
tortnation  tliat  gives  the  additional  name  of  multUobular  cinhosis 
t..  this  particular  type.  Further,  the  bands  present  relatively  few 
iiulu<le(l  ,)il(.  ducts.  Kspecially  in  the  young,  a  variant  of  this  tvpe 
i>  seen  \n  which  many  of  the  ncnlules  are  relativelv  large  (Figs  259 
:'iKt),  much  larger  than  hobnails;  a  study  of  them  shows  that  here  we 
.l<>.il  with  a  regenerative  process.  From  this  simple  regeneration  we  may 
|)iiss  on,  particularly  in  adults,  to  cirrhosis  with  multiple  adenomatous 
nodules  and  cirrhosis  with  accompanying  diffuse  carcinomatosis. 

The  cause  of  thi.s  hobnail  appearance  is  obvious;  it  is  the  old  story 
III  eventual  contraction  of  newly  formed  connective  tissue  with  resultant 
lin.jection  of  the  interinediate  masses. 


Fio.  259 


Fia.  200 


Ilol.iiailiil  liver  with  large  huhnails du-;  to  rcgen- 
■  I  iiiun  of  the  piironchyraa,  naturni  siie  (.VIcGill 
l';ith.  Mua.) 


Portion  of  the  same  seen  on 
secliuD, 


As  to  the  cause  of  "portal"  cirrhosis,  there  has  been  great  debate 
1  !.<■  commonest  type  of  alcoholic  liver  is  that  of  advanced  fattv  infil- 
tration     In  such  livers  we  notice  often  that  the  portal  sheaths  show 
a  small-celled  .nfiltration  or  slight  fibrosis.     It  is  presumed  that  some 
irritant  agent,  brought  by  the  portal  blood,  sets  up  a  low  form  of 
irritation  around  the  branches  generally,  as  also  that  the  same  irritant 
.  a.ls  to  .legencration  and  atrophy  of  those  liver  cells  which  are  exposed 
t-  the  mam  brunt  of  the  toxic  agent,  that  thus  there  is  a  coincident 
I"  np-rtal  growth  ot  connective  tissue  and  destruction  of  the  peripheral 
I  'IN  ot  the  lobules,  the  resultant  irregular  breadth  of  the  bands  of  fibrous 
i-uc  being  dependent  upon  the  irregular  distribution  of  the  portal 
■ranches  around  the  lobules.    As  to  the  nature  of  the  irritant,  it  has 
""■n  louiKl  that  alcohol  alone  administered  to  the  lower  animals  will  not 
-  r  up  cirrhosis,  and  that  acute  atrophy,  pure  and  simple,  of  liver  cells 
•  'I.  as  IS  produced  by  chloroform,  is  followed  not  by  cirrhosis  but  bv 
>'  |:n.eration  from  the  undestroyed  liver  cells.     Hcktoen,  Weaver,  and 
•  ,  jTs  have  occasional  y  noted  that  inoculation  of  laboratory  animals 
ith  certarn  strains  of  B.  coli  will  set  up  the  condition,  but  this  with  no 

o7 


f 


578 


77/A;  lilCKSTIVE  SYSTEM 


conPtaiK-y.  Recently,  Opie  has  shown  tJmt  if,  after  preliminary  ncer...s 
ot  the  liver  cells  by  means  of  rlilorof(.rm,  the  organ  he  snhjected  I 
infeetion  by  a  nuld  strain  (.f  U.  et.li  or  its  toxins,  then  constantly 
cirrhotic  process  is  .ley.loped.  'J'his,  it  is  true,  is  not  a  i)'  re  porti 
cirrhosis,  h<-cause  chlon.form  temls  to  produce  a  central  rather  than 
pcriplieral  ncrosis.  Inrh-ed  from  the  similarity  of  the  histoloijici, 
picture  produced  thus  followinj;  ui)on  a  centrilohular  necrosis,  to  thii 
seen  in  the  common  human  multilohular  type,  it  mav  he  questione 
whether  the  loss  of  Iner  parenchyma  in  the  latter  is  primarily  or  esseii 

Fia.  261 


ft 


.scion    fro.,,  a  liver  rnlnwd  nnd  showing  .omWnod  extreme  f,,Uy  im.,  ,.,iu>,    :,ud   .,KHlcr.,.e 
.■,rrho«,s.  ap„r.,x.n,,.„n^    l„»,.,l„,ieany    n.ure  ,o  Hanofs    .l,«n  to  Lnennec'.  type-  „    fat    Iv  infi 
tn...   hver  eell.,  6  and  U.  l.ile  due,,.  i„crea«.d  in  nun,bcr;  c.  rou„d-ccl,„l  infiltration  of  fij^u, 

tialiy  peripheral  and  whether  we  are  ripht  in  speaking  of  this  as  portal 
cirrhosis.  But  these ol)ser\ati(.ns  strongly  support  our  contention  that 
tliere  are  two  factors  at  work  in  the  production  of  cirrhosis,  yiz.,  in  the 
hrst  place  an  agent  acting  through  the  stomach  and  intestines  and  there 
setting  up  condii.  .is  which  fayor  suhinfecfion  (see  p.  147)  and  in  the 
second  place,  in  consequence  of  the  gastro-eiiteritis,  the  undue  passiiL-e 
into  the  portal  system  of  organisms  of  the  B.  coli  type  through  the 
damaged  mucosa. 

We  have  here  described  the  typical  form  of  portal  cirrhosis;  it  must, 
bov>sver,  be  borne  in  mind  that  the  typical  case  is  the  exception  and 


riuiiiinsis  OF  the  livkr 


.■)-9 


iH.t  the  rill.'.  In  a  larRe  numlier  of  cjises  this  very  growth  of  fihrous 
ti^>nr  within  the  hver  ha.ls  to  ^rnve  disturbance  of  the  hihnrv  system 
:"".  ^V  t"  ;  '«  •Mtercurrent  .levelopn^  .f  jaundice  aiul  c;.inci.h.nt 
irntation  of  the  hde  ducts.  Farther.  .,uiie  a  large  proportion  of  cases 
.'""r  w  "^.'''''"'"*.  "  '"•'•w'lish  piKmentation  both  of  the  liver  cells 
i.nd  of  he  fihrous  tissue,  the  pigment  being  iron-containing.  There  is 
.  vi.lently  m  these  cases  some  hem..lytic  agent  at  work  with  excessive 
h  .cnvtion  of  hemoglobin.     The  most  a.lvance.1  cases  of  this  nature 

tl"/7"'''"J^r'  I?'«r"^"*'""  «"•'  «'"«titute  the  condition  of  hemo- 
chromat«5is.  Often  in  thesj  there  is  accompanying  fibrosis  „n<l  «tro,>hv 
|.f  the  lancreas  (broiued  diabetes).  The  ascites  and  enlarged  spleen 
...  ported  cirrhosis  appear  clearly  t.)  be  associated  with  the  «,ntraction 
ot  the  hbroiis  tissue  and  accompanying  compression  of  the  intrahepatic 
portal  vessels,  leading  to  obstruction.  ^ 

While  making  this  statepy-nt,  mention  must  be  made  of  a  remarkable 
condition   known  as  Banti's  disease,  or,  according  to  Banti  himself 
hemolytic  splenomegaly.     Here,  enlargement  of  the  spleen  i    the  S-st 
.hsturbanc,.  not«l,  and  after  the  course  of  some  years  this  is  follows 
l^     .oral  cirrhosis  o    the  liver.    Banti's  observations  on  the  resul 
.1  al,  ation  of  the  spleen  indicate  that  the  overgrown  spleen  f«,^- 
."..atcs  in  excess,  the  anemia  ceasing  when  the  organ  is  removed- 
|"t!;i"!;l^i;i;    "         '         "'^  "^  ^^^^  hemolysis  that  act  as  th. 
BUiary  Cirrhos«.-()f  this  we  recognize  two  forms,  C  _  obstructive  and 
"liat  IS  known  as  Hanot's  or  hypertrophic  cirrhosis.    We  confess  that 
^w  .have  ,icv»r  met  with  an  example  that  we  coul.l  surelv  say  was 
ot  th.s  second  kind,  and  the  condition  seems  to  be  verv  rar^  in  North 

inlSi  tat.""""""  ^""  '^^'^  •^^'^■"  ^^P"^*^"''  P-«-'>' 
The  obstructive  form  of  biliary  cirrhosis  is  to  be  encountered  where 
Ion  one  cause  or  another  there  is  continue,!  obstruction  in,  or  complete 
>..;..osis  ot,  the  common  bile  duct.     It  is  to  be  seen,  for  example   k, 
la..ts  presenting  congenital  atresia  or  absence  of  the  duct.  o7xv5;e  " 
HT.  J,as  been  long-continucl  impaction  of  gallstones,  or  pressure  upon 
:'•  . Im,  fr,.,n  without  or  where  there  is  occ-lusion  b-  tumor    grow    " 
"'In.,  the  duct.     In  all  these  cases  the  liver  is  enlarged  and  sh,  w^ 
-  mne  jaundice,  as  do  the  other  tissues  of  the  bodv'    AJlthe  Ide 
ts    hroughout  It  are  markedly  dilated  and  around 'each  is  a  brS 
o n  ■   ,t  new  connective  tissue  in  which,  in  part  through  dilatation   i 
;;.;;"?'';:'"'-  P-liJeration.  a  chaplet  or  circle'of  terminal  b 
....„'      \  .''^""""*'"t'y-     "''re  dearly  is  a  cirrhosis  around  the 

1  n^X'  rr     '"'-''  ^•"  ^'  ^"'"P'*^^^'  ^-'t*'  "-^^  fibrosis  around 

■   ^ ot         esl*^'  pancreatic  duct  following  obstruction  of  the  same. 

'......,''.  't^^  *';'  T'''"'^  ,  ?  °^  *'^"  ^^-^^--^t^d  fluid  appears  to  be  the 

-.'X   o"S;E*c.ses   '"     '^'"''''''  ^^""'^  ^°"^^*"^  ^  considerable 


580 


TItK  DIGESTIVE  SYSTEM 


Hujot's  Cirrhotli.-  In  this  we  have  a  train  of  svinptonis  widtl 
•liffenMit  from  those  of  ordinary  portal  cirrhosis.  There  is  not  s«)  niarke 
pistro-intestinal  disturhance;  there  is  httle  tendency  to  ascites,  bu 
what  is  most  marked  is  a  snccession  of  nKnieratelv  acute  attacks  r 
janiKhce,  and  after  each  attack  the  liver  is  found  liirRer.  the  jaundic 
takes  a  longer  and  longer  time  to  pass  ..tf.  until  it  lu-comes  continuou 
and  the  liver  attains  an  enormous  size.  At  autopsv.  there  is  tota 
absence  of  hohnailiuK,  the  ornan  is  greatly  jau.-.diced/cuts  firmlv,  an. 
under  the  microsco|M-  the  fibrosis  is  much  more  evenlv  distributed 
Around  individual  lobules  (monolobular  cinhosis)  the  bands  are  no 
so  sharply  defined  anil  exhibit  numerous  bile  ducts,  or  more  accuratel' 
pseudo-bile  ducts,  little  worm-like,  conv(.lute<l  masses  of  cells  havinj 


w\ 


Flo.  202 


d-^ 


'^^^'^ 


S  2  S.f  ^ 


liv^  r.  .Tk  ''ver  under  „Kh  ma«m6cat.on  ,le„„.«„r„tinK  rev.THionary  met«morpho»i,  of  .h- 
Uver  cell,  at  the  penphery  of  a  ohu.le  under  the  influence  of  the  .urroumliag  fibroai,,  into  ,,,.,.11 
ccll8  appro.,m„t.ng  to  the  b.leniuct  type,  thongh  unpr„v„le,l  with  «  lumen:  a.  reduced  liver  cell, 
forming  a  paeudo-bdeH^uct;  A.  liver  cella  of  lobule  «ith  ex.re„,«  f«„y  infiltraUon;  c.  bile  duct 
proper;  d.  cells  of  pacudo-bile-d,>-t  atill  containing  fat.  showing  thus  their  liver^ell  origin. 

no  regular  lumen  and  appearing  lo  rei)re.sent,  many  of  them,  collections 
ot  shrunken  liver  cells  snared  off  and  compressed  bv  the  connecti\e 
tissue  as  it  advances  into  the  lobule.  Tins  appearance  is  not  entir.lv 
conhned  to  Hanot  s  cirrhosis,  and  is  well  .seen  in  Fig.  202.  In  other 
words,  some  cases  of  what  appear  to  be  ordinary  cirrhosis  show  here  and 
there  similar  appearances;  as  we  have  said,  a  large  proportion  of  ca^rs 
of  cirrhosis  are  apt  to  become  secondarily  of  mi.xed  type. 

The  prominence  of  the  icteric  manifestations  in  Ilanot's  cirrh„MS 
suggests  strongly  that  here  the  irritation  is  of  biliary  origin.  It  has 
been  suggested  that  it  is  due  to  an  ascending  chronic  inflammati-.n 
of  the  finer  bile  ducts,  and  that  it  is  of  infective  origin,  but  this  has 
still  to  be  surely  determined. 


.19^»«^»K.^f3^- 


Wm^ 


■■f<«J**£^ 


THE  UVKR 


581 


Fiu.  2(13 


Syp^tic  tinhodi.     1,1  H  syphilitic  stilllM.rn  infant  ..ne  of  the  most 

^triKMiK  f.'atnrrs  is  tho  nhnn.hu.tr  of  spircMhett-s  in  the  liver  tissue- 

1.1  infants  sl.owniK  syphilitic  nmnif.'stations  tlu-  orjta-i  is  apt  to  Ir.  «f 

r.h.hvely  Kn-at  s.z,..  „„,!  f,  pn-sent  on  n.icroscopi,-  examination  al.nn- 

.iHMt.  sniall-,-,.||,..|  n.hltration  in  the  form  of  widely  .liffustnl  miliary 

iriir.unas.      I  his  eon.htion  may  lea.l  later  on  to  a  diffuse  formation  cif 

.ur.n.ttive  tissue  of  what  may  l.eterme.l  the  iH-rieellular  tvin-;  not  only 

'  .""■  l^/IPh^y /'f  the  h.l.ules  but  within  the  lobules  themselves,  separ- 

...inKotl  individual  cells  and  eell  .•olumns.  there  may  he  deveh.ijtl  a 

'l.li.ate   but  extensive  connective  tissue.    Occasionally   in   acquired 

syphihs  we  meet,  in  the  s.ncalled  late  secondary  staRe,  a  similar  enlaree- 

n..nt  of  the  orRan  with  a  like  .liffuse  pericellular  cirrhosis;  also  (though 

Ins  must  not  be  consi.lered  a  true  cirrhosis)  in  the  neighb<.rhoo«l  of 

lar^e   Kimunas   wc   obserAe    a    similar    pericellular   fibrosis.     French 

authorities    lay    stress    upon    a 

>i'iiu'what  similar  diffuse  fibrosis 

stcii  ill  soineca.ses  of  tul)ercuh)sis, 

iin.i  ascribe  this  to  the  action  of 

tiilurcular   toxins;   although    we 

lia\f  sought  for  it.  we  have  not 

seen  this  form.     One  of  us  (A.) 

lias   seen   and    describefl    an   ex- 
treme   condition    of    pericellular 

•  irrliosis  in  cattle  suffering  from 

wiiat   is   known  as  Pictou    cattle 

disease,  now  recognizinl  as  due  to 

t!if  tir,-.ts  of  ciitiiif;  ragwort. 
Inflammation  of  Olisson's  Capsule. 
This  should  strictly  be  consid- 

iTcd  as  a  localized  form  of  peri- 
tonitis; it  may  be  acute  or  chronic. 

\\f  niciition  it  here  because  one 

niiijirkable  type  of  chronic  pro- 

^nssive   iijflammation   has  often,   from    the   accompanying  extreme 
s  and  great  shrinkage  of  the  liver,  been  mistaken  fcfr  a  portal 

>r  Im.ms.     1  his  IS  hyaloserositis,  or  "cake-icing  liver,"  in  which  there  is 
j;  -nsc.  porcelain-white,  fibrous  <leposit   sometimes  a  cen  .meter  o 
tliV'iiyer'wEh  Pf '-'-'•^-•-  the  upper  and  anterior  ^urfaa^ 

.  r.  hv     Son  1  f  t"f"T  ^^'  '*u  T'*™"*'°"  «''^«t  compression  and 
V  si  ;.i;r  •  ^T^'t''  *'-^'^  ^^'^^  this  is  accompanied  bv  an 
2^^>^^.  cirrhosis  of  the  liver  tissues,  but  the  cases  we  have  seen  have 
ii"t  sliowr.  any  such  process. 

The  Specific  Inflammations.-Miliary  tuberculosis  of  the  liver  is  not 
;;;'on„non  in  cases  of  general  disseminated  hematogenous  t'.W 
-     ■    Of  e„  the  tubercles  are  so  fine  that  they  are  noticeable  only 

^     ■.^Z^":'^rfT'  rl  *''''"  "'^"  •*  •«  characteristic  that 
-ciural  thej  are  isolated  and  show  little  caseation  and  appear  as 


Section  from  a  syphilitic  liver  showing  diffuse 
pericellular  cirrhosis:  a,  snmll  detached  cluster, 
of  liver  cells;  ft.  intralobular  connective-tiaiue 
formation. 


5S2 


Till-:  DIGESriVE  SYSTEM 


tliough  tl.cy  .Ic-vdup  v.iil,  ,)iffi,„lty,  sujrfrosting  that  the  tiihercle 
hacilh  do  not  rcachly  multiply  in  this  or>,'an.  Ocrasioiialiv,  lunvevcr 
as  III  the  hraiii,  we  eriCDiinter  solitary  oongloinerate  masses  of  case- 
atiiiK  tiil)er<les,  tuberculomas.  A  third  form,  the  so-called  bUe-duct 
tuberculosis,  is  descrii.ed  in  which  tiihcn  iiloiis  nodules  up  to  the 
size  ot  1  (,r  J  cm.  in  diameter,  are  disrrihiited  alonj;  the  course  „f 
the  larger  bile  ducts.  These  show  a  caseous  centre,  arc  ai)t  to  be  bile- 
stained,  and  what  is  more, 
^'■"  '"*  they  tend  to  break  into  the 

bile  ducts  and  so  to  under- 
go cavitation. 

Syphilis. — It  may   sound 
paradoxical  but  at  the  same 
time  it   is  true  that  of  all 
the  internal  viscera  the  liver 
shows  most  frequently  mani- 
festation of  the  presence  of 
syphilis,    and    nevertheless, 
considering  the  frecpiency  of 
acquired  syjjhilis.itis  some- 
what   striking    to    observe 
how  rarely  in  the  ordinary 
run  of  post  mortem  cases  we 
meet    with    syi)hilitic    dis- 
turbances   in    this    organ. 
Or  otherwise,  with  modern 
treatment  it  is  rare  to  find 
permanent  syphilitic  disor- 
ders of  the  viscera,  but  of 
the  viscera  the  liver  is  most 
frequently  involved.    At  the 
same    time,  the    syphilitic 
lesions     are    very     varied. 
Considering  first  congenital 
syphilis,  common  conditions 
are   either  widely  dissemi- 
nated   miliary  gummas   or 
a  later  stage  of   syphilitic 
cirrhosis,    but    in   addition 
,  there   are    some  few    cases 

on  reconlot  large  s(.htary  syphilomas,  corrcspomling  to  the  tuber- 
culomas already  mentioned,  surrounded  I)y  hvperplastic  liver  paren- 
chyma. Ordinary  gummas  of  moderate  size  an;  eomparativelv  rare 
111  tlie  congenital  disease.  In  acquired  syphilis,  it  is  these  ordinary 
gummas  and  the  results  of  the  .same  that  are  the  commonest  and  nio^t 
eliaractenstic  manif.'station.  We  may  Hn.l  either  infrequent  nodiiirs 
moderately  sharj.ly  defined  with  gummy  centres,  wliich  may  be  2  or  3 .  !.i. 


Section  from  ii  guniniiitous,  syi.hilitic  liver,  showing  at 
a  necrotic  igunnnyj  ccntrul  area;  h,  lonc  of  leukocytes 
umlcrgoing  necrosis,  c,  ,;  lone  of  abumlunt  small  round- 
eelled  infiltration;  d  J,  outer  jone  of  fibrosis,  extending 
outward  liedveen  the  columns  of  eoniprcseed  liver  cell.,  at 
c;  /bile  duet. 


SYl'llIUS  AM)   THE  UVKIi 


5S3 


FlQ 


in  cl.ameter or  more    frc-qucntly  there  is  preso.it  one  or  other  later 
^ta.tre  m  the  history  nt  the  same.     The  ten.h-.Kv  is  for  these  gummas 
iiiiMer   onhi  iry   con.htioiis   to   under-o   ahsori.tion.     With   this    the 
n.crosed  centre  un<UTj,'oes  shrinkaRe  an.l  sinniltaneouslv  there  develons 
.1  very  pronouncecl  surro.mdii.jr  fibrosis.     This  often  takes  the  form  of 
r.„l>al  ,>rocesses  ot  fair  size  extemling  for  so-     ..rr'..  distance  hetvveen 
-!..■  lobules.     The  shrmka«e  that  this  inHa..  .atorv  Jih.^u-    issue  mav 
M.id.TKo  IS  very  strikms.  and  tlie  result  is  th  .t  t!..  .nerl.inr  liver  tis-ue 
1^  pulled  m  and  the  surface  of  the  liver  slu,  ,s    v.li-maike     distortion, 
nM..n!,hnf|,  to  eniploy  a  homely  simile,  a  seat  .,,1,  .l-i  <  ,1  hv  tb-  button 
m.thod    there  bem^  deep  unpressions  with  stellate  furrows  radiatini: 
Irn.n  the  bottom  oi   each.     Where  these  cicatrices  are  abundant  we 
;|i.tau.  the  Kreatly  .listorted,  coarsely  lobatc  liver,  the  hepar  lobatum. 
1  Ins  distortion  appears  t..  be  permanent;  we  may.  in  old  svphilitics 
.Meet  with  these  dci)ressions  which  show  at  their  base  a  small  amount 
lit    cwatricial  tissue,    running; 
into  the   liver   tissue,  but   e.\- 

liii)itinjr  no  sij,'n  of  the  typical 

:,nuiinia,    the    ^nminy    matter 

liMviiijr  l)een  wholly  'al)sorbcd. 

A^  already  noted,  there  may 

lie,    tli()UKh    rarely,  a    ditfusV 

-yi)liilitic  cirrhosis,  and  sonie- 

uiiat  more  frequently  than  in 

tlic('on«;ciiital    form  we  may 

-iinilarl.x    i-ncounter  hu>;e  soli- 

'ary     syphilomatous     inasscs, 

uliiih  may  easily  be  mistaken 

fur  tumor  growths, 
^pcakinj;  of  errors  of  diaj;- 

iiiisis,  it  deserves  mention  that 

'li<'\vphilitie  cicatrices  if  situ- 

j't.d  near  the  hilus  of  the  liver   may  so  compress  or  pull  upon  the 

l.iru.T  portal  veins  as  to  cause  obstruction  an<l  ascites  and  lea<l  to  a 

-w|.|.ns,t.on  that  we  deal  with  a  case  of  portal  cirrhosis 
Actinomycosis.     Actinomycosis  is  somewhat  apt  to  involve  the  liver 

-  a  metastatic  process,  and  there  may  be  multiple  small,  frranulomatous 

,.as,.,niorecharact,.istic-ly,sd^ 

I'  n.»,  clK,racteri/ed  by  a       newhat  six.njry  appearance. 
Regressive  Changes.     Auophy.-.^impl,.  atrophy  is  seen  in  old  a^re, 

,•:;""  T"""^  T'^'- "■  """"t"""^-    ''''"•  'TKan  is  small,  with  shiu-p 

n  .  ie       •  '^"'•''^"''"•'•^-  •'•*'':;  '^-ft  '•»''^''  "'""«  the  edge,  there  mav  be 

;  ""pl,.ted.sappearanceo  thehver  cells,  the  connective  tissue  framework 

">„■  rcmaimnj;  as  a  whitish  continuation  of  the  liver  tissue.     Under 

li;  •"•[•'■'-"•P'Nthe  lobules,  columns. an.l  cells  are  small.and  throughout, 
ulls  may  show  small  accumulations  of  brownish  pigment  (browii 


Surface  of  syphilitic  liver  to  show   the  chanicteristic 
puckering  (,i, ,,)  over  old  fibroid  gummata. 


584 


THE  DIGEST IV K  SYSTEM 


depression  (p  572)  or  I-.^tN-  ..  •  Ti     ^^^^^   '^-  •"'')-  or  i.s  the  cardiac 


Via.  266 


Fia.  267 


Teased  cells  from  a  fattily  infiliralcl  liver:  „,  nuclei 
being  pushed  to  the  peripherj-. 


Tensed  cells  from  a  liver  showing  the 
curlier  stniic  of  fatly  infiltration,  with 
multiple  fat  droplets  of  varying  size 
distributed  in  the  cytoplasm. 


ami   la  th      „      »:  h?"  "'T  "'"?  ''^  tuherculosis  and  ,.ther  cachexias, 
cdt  are    ,;  first     vn'  T  -f"  "    P'-^'«"""c-y.      While  the  peripVn.l 

may  reS    tit  "j  /'  f  •'••^;"'^'  '"">• .?'" V»"  ^''^  ''"-f-'^^^t  store  of  fat.    ^^o 

t^  oeH  Udv  i     ?>         •  r]'  r  "'"  *'"'  "■"  ""^'^"^^  ^till  stains  well. 
pI«riJ      •    1        "  clistended  f,y  one  or  more  large  fattv  elobni.s 

tTcell  bodv  I  '  ^f"'  '•^'"''^'^'  •"•  ^"">'  "«««'•  throughmit 

S't^elltTHf """'">'•    ^^"'^  "^  '-^  (^f^^-)  ^ith   Professor 
Mot.  has  called  attention  to  (he  frequency  of  this  condition  and  has 


■  •til, 


THE  UVER-DEGEXEIfATlOXS  -.s;, 

suggested  that  the  irregular  and  angular  form  of  the  granules   when 
stan.ed  with  Sudan    II.  indicates  tlu,    .ve  .leal  not  with  oJdi.urv  ^eu  ra 
tats  but  with  some  fatty  compound  or  lipoid.    This  fattv  degt-nen  tio 
MHv  u-  either  umversal.  peripheral,  or  central  in  position  in  tl  "  obnle 

.  n  itT',:\"';r.f ?•'  *°  ""^'^^  *'^^  ™^"^"'"«  «f  p^'-t'^-'ar  <iist  i »: 

;.  n    T     "  *  '"\'"  J^r'^^"'  *'"'^'"'*  the  degeneration  is  general  v 
ut  the  centrl  type.     As  a  further  distinctio        ^ween  the  liver  of  fat  v 
infiltration  and  that  of  fatty  degeneration,  it  mav  be  said  that   n  the 
tornier,  the  organ  is  large,  with  round,  obtuse  edges,  pale  and  so  icl 
w.th  a  greasy  cut  surface,  while  in  the  latter,  the  liver  is  flabbv.  sh  ui  ken 
',    n  voTl'        ;*  T"  ""*"'■"'  '^"'*''"-     ^"  P'"«Phorus  poisoning  ad  in 

Fio.  268 


Glycogenous  infiltratioii  may  be  encoimtere.I  in  the  peripheral  cells  of 
•  W.ule  in  certain  cases  of  diabetes;  in  some  of  thise  case's  n-c'th 
A^vl'o-'f  "/':r  r"  ''V^^'^ted  actually  within  the  nuclei.  ' 

Amyloid  ot  the  liver  is  seen  in  general  amyloi.losis,  associated  with 
miliar  change  m  the  spleen  and  kidnev;  when  advance.!   th     K-rr  ;= 

-  -gcd.  firm,  and  the  waxy  areas  are-pr.>ininent  ^m^  '  ^..  ^^ 
irt.ice.     Microsopically.  it  ma\  be  observe.l  tint  th.-  rlnnnit 

HH  ,h,r.^  .,f  the  lobule;  later,  the  amyloi.l  .leposit  mav  affect  the 

-  i^'Ie  l..be.  causing  great  atn.phy  of  the  lix  er  .rlls  .roper 

Pyental  Inmtration.-TI,c  pigment  .ieposite,!    n    he  liver  mav  be 
•'  "'>«m-nt  kin.ls.  VI..,  bile  pigment  (bilirubin),  iron-frei  der  vad^es  of 


'\ 


5SG 


Ti:E  DIGFST^VK  SYSTEM 


blood  pigment,  and  I.o.nosiderin.  In  icterus  or  jaundice  the  heaping 
up  ot  the  i)iKinent  is  scti.  nriuiarily  within  the  liver  cells  and  here  at 
times  It  can  be  recogniz-  1  that  it  occupies  a  set  of  fine  intracellular 
channels  In  more  advanced  cases  the  inspissated  bile  is  f,„nid  also 
m  the  bile  capillaries  between  the  liver  cells  an<l  deposited  in  the  Ivmph 
spaces  of  the  portal  sheaths.  According  to  degree  of  pigmentation,  the 
liver  may  exhibit  a  bright  yellow,  a  pn.nounced  brown,  or  even  a  dark 
olive-grecn  color  upon  section.  We  have  considered  the  causation  and 
torms  of  icterus  on  p.  323. 

Iron-containing  pigment  is  recognized  in  the  form  of  fine  (hemo- 
siderm)  granules  siti.ate.1  along  that  border  of  the  cell  which  impinges 
upon  the  bile  capillary;  in  advanceil  cases  it  may  be  seen  even  in  the 
periportal  connective  tissue;  it  takes  on  a  Prussian-blue  stain  with 
solutions  ot  i)otassium  ferrocyanide  after  treatment  with  acid   and  is 
very  i)ronounced  in  cases  of  pernicious  anemia,  hemochromatosis  and 
those  intoxications  m  which  there  is  excessive  destruction  of  the  red 
blood  corpuscles.     The  liver  in  these  cases  has  a  distinct  rustv-brown 
color  on  section,  unless  the  fat  is  so  extreme  as  to  give  it  a  paler  vellow 
Accompanying  this  iron-containing  pigment   there  are   wnerallv  to 
be  seen  yellowish  pigment  granules  which  do  not  give  the  Pi  assiaii'blue 
reaction;  these  are  spoken  of  as  hemofuscin.     Similar  gran  iles,  often 
agglomerated,  are  to  be  recognized  in  the  atrophving  cells  in  the  con- 
dition ot  brown  atrophy. 

A  characteristic  form  of  pigmentation  may  be  encountered  in  recur- 
rent malana  when  the  liver  assumes  a  bluish-grev  or  even  a  dark 
chocolate  co  or  The  pigment  in  these  cases  is  found  in  abundance  in 
the  endothelial  cells  lining  the  portal  sinusoids  and  capillaries  as  also 
in  Kupffer's  star-ceUs,  occasional  cells  which,  on  the  one  hand,  impinge 
upon  the  blood  stream  and  so  Inne  an  endothelial  character,  and  on 
the  other  penetrate  between  the  liver  cells.  This  pi^^nent  is  obviously 
(lerived  trom  the  central  pigment  deposits  in  the  bodies  of  the  hem- 
ainiebaN  left  free  in  the  blood  after  spornlation,  and  obviouslv  also 
IS  a  metabolic  product  of  the  hemoglobin  of  the  ervthrocvtes  absorbwl 
by  the  growing  parasites. 

Calcification.  There  are  on  recoril  a  few  cases  of  extensive  calcifica- 
tion ot  the  hver  associated  with  previous  extensive  necrosis  of  the 
lobules. 

Necrosis.— The  commonest  form  of  necrosis  in  the  liver  is  met  in 
the  forni  of  multiple  minute  and  discrete  areas  of  cell  death,  in  manv 
arute  wfedmis.  Experimentally  these  can  be  produced  by  several 
toxins^  \\e  have  discussed  the  theories  regarding  their  causation  on 
p.  .iZS.  In  clilorofonii  pmmmnq  more  extensive  necrosis  may  be  seen 
attecting  the  central  zone  of  the  lobules  and  in  permcious  anemia 
occasionally  a  similar  central  necrosis  may  be  found.  .Alore  extensive 
areas  ot  necrosis  may  occur  in  eclampsia,  the  etiologv  of  which  is  still 
unknown.  I  he  necrosis  may  be  extreme,  involving  a  large  part  of  iIk- 
entire  tissue  of  the  liver.    Similar  very  extensive  necrosis  characterizes 


THE   '  /  YER~DEGE\ERA  TWIN'S 


587 


tl.c  condition  of  acute  yoUow  atrophy  an.l  an  almost  identical  picture 
IS  seen  ni  acute  phosphorus  poisoning.      In  any  of  these  states,  where 


Focal  necrcna.  Section  from  a  typhoid  liver 
<xliibitin(j  at  a  the  early  stage  of  uncompli- 
tilled  necrosis  of  a  email  urea. 


Fio.  270 


Section  from  the  same  liver  exhibiting  a  later 
stage  of  focal  nerrosis  with  small-celled  infiltra- 
tion into  the  necrotic  area:  a,  necrotic  centre. 
In  a  later  stage  the  small  cells  completely  remove 
and  replace  the  necrosed  liver  cells. 


^^<TllTaTJr^"^""  ^°^''"  r"-"""^'^  '"   ™'   •""^^»  "'  '•"'  'o'"''"'^    »•  ^<--"«  of  lobule 
-^^h  Jc,  and  shrunken  remaining  Uver  cells;  *.  po.    d  vein;  c,  c.  c.  c,  portal  sheath  at  periphery  of 

■!.<•  toxin  has  evidently  been  very  strong,  followed  quicklv  bv  death,  the 
•tils  are  found  m  a  condition  comparable  with  coagulation  necrosis; 


588 


THE  DIGESTIVE  SYSTEM 


Fjo.  272 


•'i'v! 


portaUhoath.  with  some  small  Ji,  J ^6^'!  "'"°*  ''""'""^   "•  '"'"""•'  "-'  "'"'^  '•  « 


Fia    273 


shown.  *"■  "-'"•=   <*'•     The    jumbling"   of   the  affected  cells  i.  well 

t&^u,Uo^  ""  '""^^^  ^'^«  ^''^  S"d-  "I  -ction  for  fat. 

It  used  to  he  the  custom  to  ron^ider  anite  vcllow  atronhv  as  a 

cund.t.on  su.  genens.    Now  we  are  coming  to  ^cognize  tit  'several 


THE  1. 1 VEK^  TV  MORS 


r)89 


different  iiitoxic-aticms,  such  as  the  eclamptic,  phosphorus  poisoninE, 
and  the  exhibition  of  chloroform  may  all  produce  a  verv  similar  picture 
so  that  the  term  acute  yellow  atrophy  must  he  applied  only  to  those 
conditions  of  extensive  necrosis  in  which  the  causative  agent  remains 
undetermined.  Such  cases  seem  more  frequent  in  women  than  in  men • 
in  the  ear  her  stage  the  shrunken  liver  has  externally  an<l  on  section  a 
hright  yellow  appearance  (yellow  atroph>).  With  complete  necrosis 
and  disintegration  of  the  cells  there  follows  an  adaptive  dilatation  of 
the  capillaries  with  occasional  hemorrl  .:ges,  so  that  now  intensely 
congested  areas  alternate  with  or  are  interspersed  among  those  still 
retaining  the  yellow  color  (acute  red  atrophy).  In  cases  of  red  atrophy 
not  rapidly  fatal  there  is  further  an  extensive  small-celled  infiltration 
with  indications  of  active  regeneration  in  the  form  of  budding  and 
worm-hke  processes  from  the  bile  ducts.  It  seems  probable  that  with 
recovery  there  may  develop  a  cirrhotic  condition. 

ProgresMve  Changes.-Hypertrophy  and  regeneration  of  individual 
l..l)ules  may  be  seen  as  above  noted  in  non-fatal  cases  of  necrosis,  and 
also  in  cases  of  portal  cirrhosis,  where  nodular  areas  of  such  regenerative 
liyi)erplasia  are  seen;  as  already  stated  these  mav  pass  on  to  irregular 
mil  ticentric  adenomatous  or  even  carcinomatous  overgrowth.  Loss 
..t  liver  tissue  is  followed  by  no  new  formation  of  lobules  but  those 
in  the  neighborhood  of  the  loss  umlergo  pronounced  enlargement  the 
cell  columns  actually  proliferating.  It  is  now  fullv  established  that 
regeneration  may  occur  by  two  processes,  viz.,  by  i>udding  from  pre- 
existing bile  ducts  or  by  proliferation  of  preexisting  liver  cells. 

Tumors.— Cavemoma.— A  common  abnormal  condition  found  in  the 
liver  IS  the  presence  of  one  or  more,  sharply  defined,  generallv  small 
areas  of  deep  red  color  (see  Figs.  130  and  131).  On  microscopic'exami- 
nation  these  are  seen  to  be  composed  of  greatly  dilated,  communicating 
•  a  pillar,  channels  filled  with  blood  or  containing  thrombus,  with  no 
intervening  liver  cells.  We  have  discussed  these  on  p.  279  and  pointed 
"lit  that  strictly  speaking,  they  are  not  tumors  proper. 

1  rue  fibromas  and  other  benign  connective-tissue  tumors  are  rare 
'i>  also  primar>-  sarcoma  and  hemangioendothelioma  are  infrequent. 
'II  the  other  hand,  secondary  sarcomas  are  not  uncommon,  and  the 
ii\er  IS  notably  a  favorite  seat  for  multiple  metastatic  melanotic  sar- 
comas.    A  few  cases  are  on  record  of  included  adrenal  tissue,  and  of 
rnniors,  hypernephromas  or  mesotheUomas,  originating  from  the  same 
1  ^^(>  lorms  of  adenoma  are  to  be  recognized,  viz.,  the  tubular  adenoma, 
•Mdently  originating  from  and  to  some  extent  reproducing  the  cubical 
[>r  colnmnar  epithelium  of  the  bile  ducts,  and  the  true  liver-cell  adenoma, 
>n  which  the  cells  are  arranged  without  lumina  and  reproduce  irregularly 
t  •-'  structure  of  b-patic  parenchyma.    The  multiple  nodules  of  hvper- 
I'lasia  already  described  partake  of  this  tvpe. 
Solitary  primary  carcinoma  of  the  liver  is  rare;  a  large  solitary  meta- 
tasis  from  some  minute  and  obscure  primary  focus  must  not  be  mis- 
'Ken  for  such  a  primary  grow.b.    In  short,  very  careful  search  must 


rm 


THE  DKIF.KTIVK  SYSTEM 


»' 


s\ 


tht  I,  cr.     A  r„„s„kTal,l..  „,n„lHT  „f  rases  „f  .liffus,.  .arci.u.inatosis 
sec.n.lary  t.,  r.rrl.os.s  an-  r.-cnl.-.l.     A  s,nall-,rll...l  form  .,f  carci,,,  ma 
of  srirrhous  typo  .s  l,y  so,....  l,.].!  to  oriKi,.at.  fro,.,  tl.,-  I.ile  .lurts      Z 

eons,.lm,.|r  >u.y  l,(-,.at,c  ,ar<i,.o,..a.  tl.e  possil.ility  of  its  origin  from 
.e  Kail  1,1a.  .I..r  „.„st  always  he  kept  i,.  mi,..i.  ......suleri..^  the  j^re^t 

frequency  (.t  caiieer  .,f  this  orjia,..  '^  J^rtat 

While  thus  primary  ear(i,..,ma  ..f  the  liv.-r  is  .listi„<tlv  uncommon 
there  .s  „„  ..rKan  „.  the  ho.ly  which  is  more  fr.-q„e,.tlV  the  sea    of 
secndary  cancerous  ^r.-wths;  ,„.,re  parti,.ularly  in  .-arcinon.as  of  tk 
sto,nacl.    pan.Tcas    .PsophaKUs.  intestine,  and  ovary,  is  the  liver  apt 
to  he  aflr..ct,-cl,  a...l  the  secon.lary  ^r.-wths  n.ay  he  extraonlinarih 
ah,  n,la..t  an.l  some  of  then,  of  very  great  size.     As  a  .onsequence  the 
mtr  niay  h.-  relat,vely  enormous,  the  nodules  ..ften  being  paloahle 
thr.„.gh  the  skm.     On  exan.ination  of  such  a  liver  the  nodu.erSan 
out  as  well-define,   masses,  whitish  against  the  c.ngested  liver  tiss,"e 
the   surface   n...lules   frequently   present   umhilication    (a   crater-lik.' 
depress,on    ow.ng  to  aut..lysis  an.l  absorption  ..f  the  .-entral  arer s 

Cysts.-Hepat.c  cysts  are  .,f  two  main  ohLts,  retention  cvsts,"  and 
parasitic  cysts,  ,lue  to  the  gr.)wtl.  .,f  e.l.inococcus  within  the  organ! 

Bile  cysts  n.ay  be  sohtary,  due  t..  the  obliterati..,,  of  an  individ,.al 
l),le  .luct,  either  .■ongcntal  or  acquired,  or  may  b.-  small  and  m.iltiple 
scarcdy  v,sd,le  to  the  nake.l  eye;  this  last  con.Jitio,.  is  seen  in  wh  has 
o2t  r'"'''  '-""^  t'K-^Tation  of  the  liver,  a  cong.-,.ital  state  f.,u,?, 
son  t  mes  assooatcMl  w,th  s,n.,lar  multiple  cystic  .levelopnient  in  the 
k  dncvs  and,  ,t  may  be,  also  in  the  pancr.-as.  The  co.ltents  of  bile 
tAs.s  are  generally  watery  ,n  appearan.-.-.  l{are  .-as.-s  are  .lescribed 
in  wh.ch  cyst,  due  to  cngenital  abnonnality  .,f  the  bile  ducts  possess 
a  cil.ate.l  ej)ithehum.  ^ 

Parasitic  cysts  an-  .lue  to  the  .levelopn.ent  i,i  tl...  liver  .,f  the  echi,...- 

liisZt'"?  T  "•'•■'','■'  '*"^'  ^^''^^'^^^-     '^''"^  'y'^''  P''-''«^'  "•  tl.e  life 

o  h  cl  t.  7"  ^"^  !"'"T"r  T^  '''^'  '•■'  *^^"  "'"i"  f"""^'  i"  ">'^- 
h  nr  """"t"'"  «'    'I""Khter  cysts  takes  place  whoUv  ..n  tl..- 

inner  asi>ect  of  the  capsule,  and  in  the  .)tl.er.  rarer  form,  ..„"the  out- 
si.le   so  that  ..umcrous  ,„.  h  ing  smaller  cysts  develop  (multUocular) 

c';n;r  Tl  ""''  T'''^.""'"',  "1  '"^r"'  *''^"  «PP--nce  of  a  .•..lloi:i 
fin.  1  '  ^P^f^*?*  ^'r  '!>'«*"'  >^  'l""f^l'".  consisting  ..f  an  outer 
hi  el-"'''  I":T"*^'^''>'  \'r'  "•"t»t..l  tissu..  of  the  liver,  a,„l  a.,  inn.r 

o okl  s  ,„  the  hud,  rec...gmzable  by  the  micros.-., p.,  is  the  cbara.t.-r- 
ist^  .l.agnost,c  t.-ature.  0.-cas,.,nalIy  the  parasites  .lie,  and  the  .■^•st 
contents  underg.,  absor,,t,.,n,  l„-ing  ultimately  re,)r..sente.l  bv  a  fihn'.ns 
c.<-atr,x  w,th  a.,  irregular  shrunk.-.,  .-avity  in  which  l..,oklets  mav  still 
he  toim.l  Some  thr.-e  .,r  four  cas.-s  .,f  coccidiosis  .,f  the  liver  are  on 
kZ  ■    ,^.^'7  P'-f^f  ^'^  "f  t\n'\\y,T,  n.,t  .ansing  .-yst  formation,  but 

duo.ienun,,  are  distomum  (several  species)  an.l  rarelv  ascaris  lumbricoides. 


K^M\ 


■■«r^K^ 


GALL  OLA  DDK  J{  A.\D  DVCTS 


501 


.     OALL  BLADDER  AND  DUCTS 

AbnonnaUtifts.— Complete  absence  of  the  pill  Madder  lias  been 
rirorded  and  ecasionally  it  may  hang  eompleteiv  free  from  the  liver 
its  relation  to  the  liv«T  edjje  is  very  variable.  An  important  abnor- 
inality  is  congenital  atresia  or  complete  obUteration  of  the  eommon  bile 
diK't,  leadmjr,  with  i)roj;ressive  jaundiee,  to  inevitable  death.  Hemem- 
h.riii),'  that  the  liver  is  a  tubular  outRrovvth  from  the  duodenal  region, 
a  is  obvious  that  such  obliteration  must  occur  after  the  definite  differ- 
entiation of  liver  and  duets. 

Circulatory  Disturbances.— <Edema  is  a  not  infrequent  condition  asso- 
ciated with  general  anasarca.  Submucous  hemorrhages  are  occasionally 
-fcn. 

Inflammation.— There  is  still  debate  as  to  how  bacteria  most  com- 
inoiily  enter  the  gall  bladder,  whether  by  excretion  through  the  liver 
troiii  the  bloo<l  or  by  ascent  of  the  duct  from  the  duodenum.     This 
imicli,  however,  is  dear,  that  at  operation  and  at  post  mortem  a  large 
I)roi)ortion  of  samples  of  gall  bladdtT  bile  aflord  cultures  of  one  or  more 
lorins  of  bacteria;  the  i)resencc  of  these  bacteria  favors  the  development 
"t  cliolecystitis.     This  inflammation  mav  be  of  various  orders     The 
••..Munonest  is  sinii)le  catarrhal  cholecystitis,  an  inflammation  character- 
i/.'.l  In-  congestion,  active  proliferation  and  freeing  of  the  columnar 
..IN  ot  the  mucosa  into  the  bile,  together  with  markedlv  increased 
.x.retion  or  discharge  of  mucin.    The  mucosa  is  found  swollen,  turbid, 
infiltrated  with  round  cells,  and  covered  bv  a  laver  of  mucin    and 
Miasniiich  as  the  common  and  cystic  ducts  mav  be  involved  (acute 
cholangitis),  the  swelling  is  apt  to  lead  to  obstruction  and  as  a  sequence 
t. .  jaundice  (acute  catarrhal  jaundice) .    This  condition  mav  be  recurrent 
.T  (ontinued  over  long  periods,  and  then  as    <iated  with  a  pohpoid 
..N  .T-rowth  of  the  mucosa  of  the  gall  bladder  or  sometimes  with  sec-ond- 
MPy  atrophy  and  thinning.     Particularly  in  these  long-continued  cases, 
a-  already  noted  on  p.  820,  the  altered  composition  of  the  bile,  and  thf» 
I'lvsiiice  of  cell  debris  and  of  mucus,  and  the  direct  action  of  the  bac- 
t.'ia  from  the  bile,  together  with  its  stagnation,  act  in  concert  as  factors 
HI  the  production  of  gallstones.     Once  formed  these  gallstones  in  thcm- 
M  Ives  act  as  a  continued  irritant  and  in  this  association  it  is  interesting 
I-.  note  that  over  00  per  cent,  of  the  cases  of  cancer  of  the  gall  bladder 
ait<.ril  a  history  of  the  presence  of  gallstones. 

Suppurative  cholecystitis  is  most  frequentlv  found  associat.>d  with 
'ii.se  same  gallstones,  but  may  present  itself  in  cases  of  severe  infection 
'  .'/.,  i^ome  cases  of  typhoid  aiid  pyemia.  Ver>-  frequenth-  such  suppu- 
I'lti""  IS  seen  to  be  secondary  to  complete  or  partial  obstruction  of 
iiif  e,\stic  duct  from  preceding  non-purulent  inflammation.  As  in  the 
■u>!><'n.lix,  so  here,  stagnation  appears  to  favor  the  proliferation  and 
'"Teased  virulence  of  bacteria,  so  that  what  was  previouslv  a  simple 
"-'""ics  now  a  suppurative  process.    Associatetl  with  this  purulent 


.')n2 


77/ A'   l)l(!F.STI\  F.  SYSTEM 


li.ll 


ron.litu.i.  tlu-n-  may  l„.  „,.,.r..sis  of  tlu-  mucosa  witl.  ul<rrati„n,  an.I  a 
tmu-s  Ka..Kn.,u-  of  tlu-  .1,.,.,,  lay.rs  of  the  wall  a.ul  ,,.-rforation;  as  , 
n-snlt  th.;n-  may  I,,-  .-ith.T  a  I.Kalizf.l  purulent  pericholecystitu  (localize, 
IHTi  ...litis)  or  jr..neral  peritonitis.  The  bile,  wh.-n  it  eseapes  into  th, 
peritoneal  ••avity.  as  pointe.l  ont  l.y  Hunting,  has  in  itself  .lireet  irritative 
an.l  neeroti,-  em-ets  This  ne.rosinK.  ulcerative  form  of  eholecvstiti- 
IS  often  aeeompame.!  by  a  superficial  membrane  formation  upon  tlu 
...uer  surface  o  the.  ,.,11  bla.l.ler;  more  rarely  this  is  seen  i„  the  hZ 
Mile  flucts.  Ihe  suppurative  fo.m  may  occur  not  onlv  in  the  uall 
DIadcler  but  also  around  impacted  gallstones  in  the  ducts.  From  this 
perforation  either  of  the  pdl  bhulder  or  <,f  the  larjjer  ducts,  there  mav 

caMtj,  but  where  time  has  l)een  affonled  for  adhesion  with  neiLdiboriiii: 
organs,  the  contents  may  make  their  way  into  the  interior  of  viscera 
-Notably  there  may  be  fistulse  between  the  ^all  bladder  and  bile  ducts 
on  the  (,ne  hand,  and  the  stomach,  duodenum,  ileum,  colon,  or  the 

;tu,een    r        T  f  ^''7*«"  f'""'-^  '"'  •"^""  "»"  *'""  ^"'"k  that  has 
not  l)een  the  seat  ot  such  fistula. 

Two  widely  contrasted  states  of  the  ^all  bladder  resulting;  from  inflam- 
mation may  at  times  be  encountere.1.  With  obstruction  and  suppura- 
tion the  orKan  inay  be  hugely  distended,  and  on  section  found  to  be 
converted  into  a  bafc  of  pus;  on  the  othe  '-.uid.  in  cases  showine  evidence 
ot  lonK-continue.1  inflammation  witlnu*  truction,  the  laving  down  of 
increase  fibrous  tissue  in  the  submucosa  is  followe.1  bv  pronounced 

as"nn:i  TV;:'-  !  "'  f '•'  '''T  "'"•'■  ''^'  '•^'P"'^''"^^''  hy  a  mass,  as  lon^ 
o  Zf  r  thicker  than  a  finder  practically  shrunken  up  ami  devoid 
ot  (ontents.  Not  intrequently  this  latter  condition  is  associated  with 
extensive  organizc.l  adhesions  to  surroiindiiiK  structures,  evidence  of 
a  previous  acutv  inflamniatioii. 

As  ori^inatiufr  from  previous  inflammatory  .listurbances,  though  in 
Itself  not  a  sign  ot  .-tn,.  inflammation,  there  may  be  noted  the  striking 
condition  of  hydrops  cystidis  feUea:  the  gall  blad.ler  is  found  pale  or 
i!  !!!rwf  *rf  "f  "'^'."t'  /";'*[>•  «li«ten,le<l.  and  on  section  discharges  a 
fluid  wholly  .h-void  of  bile  but  shimmering,  if  not  milky,  with  abundant 
cholesterin  crystals      I  he  process  in  the  .levelopment  of  this  condition 
IS  usua  ly  catarrhal  inflammation  with  obliteration  or  blocking  of  the 
c.vstic  duct,  either  by  overgn.wtli  of  the  mucosa  or  by  means  of  a  stone. 
Ihe  contained  bile  .Muses  out  and  at  the  same  time  fluid  and  mucus 
are  discharged  fn.m  the  muc.)sa.  lea.Jing  to  progressive  distension.    The 
atmudant  cholesterin  suggests  that  there  is  a  continued  state  of  mild 
inflammation  of  the  mucosa,  with  dissociation  of  the  epithelial  cells 
or  actually  increased  excretion  of  cholesterin  or  some  precursor  thereof, 
such  as  cholesterin  oleate. 

The  i- fective  granulomas  rarely  affect  the  gall  bladder  and  larg,  r 
biliary  passages.  '^ 

Progressive  Changes. -^Tumors.-The  main  tumor  to  be  considered 
m  connection  with  the  gall  bladder  and  bile  duets  is  carcinoma,    litnign 


THE  PANCREAS 


:m 


nn.mrs  arr  so  ran-  that  thry  may  hr  passe,!  ..v.-r;  the  sam.-  is  tnu-  „f 
till'  pninary  sarcomu. 
Cardnom*  iiu.st  ..ftni  ...iKinatt-s  in  c(.M.KTti(.n  with  th.-  ^all  l)la<l.|,T 

'"".'""■:  "'' rur  al.u.K  th»-  fonrs,-  of  the  hir^.-r  .iuct..  ..itiuT  i.>  the 

^V.i.-  .hie  ,  or   at  its  jum-tion.  within  the  eomn.on  ,h.,  t  or  ap,in  at 
'"'  ""•';"'"  *:^^"'r'--  /  an-inoma  of  the  p.ll  l,Ia.l.ler  most  frem.entlv 
^  nus  itseH  e.ther  ,„  the  fnn.h.s  or  ut  the  neek;  at  the  fundus   eier 
tlirou^h  the  «rav.tat.onal  presence  of  gallstones,  or  at  the  neek  in  asM- 
ci.  ,o„  w.th  the  arrest  ot  the  san.e  in  their  passage  to  the  ,iuot.     We 
-.1. .   here  en.phas.ze  that  this  is  one  of  the  frequent  sites  of  eareinon.a 
uH.hly  ..  per  .-ent,  of  eases  of  carc-inoma  arising  here.     The  tvpieal  fo     .' 
> ..  M.lt.  .■olunu,ar-<elle.    a.lenoeareinoma  t.-n.linK  «.n  the  one  han.l  to 
orm  a  mass  ,,rojeet>ng  mt«  the  gall  himi.ler.  an.l  on  the  other  to  inHI- 
tr:...;  ..xtens.vely  the  wal  ami  th.-  liver  tissue;  hut  variations  are  foun. 
At  tmies   there  is  al.un.lant  stroma  formation  with  alveoli  filled  with* 
roM.ul  jells  an,l  the  general  characters  of  a  sc-irrhous  growth,  ami  sev  'r 
.^vm.ples  are  ,-ow  on  reeor.l  in  which  through  metaplasia,  presun.ahlv 

'ln.t.M.rm..n.gn.Hamn.at,..n.th..tum..rapproximatestothesquamous- 
;.    ■-   .■I..tlu.ho„,atons  type  or  shows  a  combination  of  epitheliomat.    s 

M.I   .len..carcn.omatousstructure(seeFig.l22,p.272).    Theremavalso 
;..      .."«h  rar,.|y,  cases  ,,f  coll.,. 1  cancer.     Here,  as  in  ch..lelithiasis  t  le 

-  ht> o„  ,s  m.^e  .•..mn.oi,  n.  the  female  than  in  the  n.ale.     In  a.l.lition 
I' .  M.  .hr..,.t  ■nhltn.tion.  there  are  apt  to  l,e  large  no,lular  metastases 
-;     "Pl. .....les  at  the  h.lns  an.l  in  the  mesentery,  an.l  in  the  perit..neum 

u.M  as  ,s..Iate,l  no. h.iar  metastases  in  the  m..re  .li.stant  p.rts  .,f  the 

■..I  i;h:i7'"';T      " •  '"'■^'■'"  '"■'*' •'""^^ "'"" "f  *'»'  ^«"'-'  t>I- »^  those . 
l.n    .1     the  latter,  an.l  as  a  consequen.-e  are  foun.l  of  smaller  si/- 
ron.  the.r  regu.n  ..f  orign,,  they  necessarily  lea.l  to  .,hliteration  .,f 
-^  ............   „le  .lu,.t,  an.  to  fatal  jaun.lice  or  through  their  ulcem  i  . 

I.'  a.  t.r  to  n  h'ctu.n.     (  arcmomas  of  the  amj.ulla  of  Vater,  it  must 
•  '■.■.nc,nl„.re,l.  n.ay  .,rig  nate  either  fron,  the  ,nue.,us  n,embra  u  . 
'!'•     .rnnnal  portu.n  of  the  bile  ,hu-t  or  from  the  .iucMlenal  mZ 
"i"nl,rane  covering  the  ampulla.  'HHMienai  mucous 


THE  PANCREAS 


-'liti.''fnncS.""!;"""^  i"  a  different  way,  the  pancreas  subserves 
"pi,    Juncti.  lis;  as  reganls  its  excreti,.n  it  affonls  a  tr^•psinoi:en 

1    i^tiSr   7'\  '  r  ^"*-"''^'"»-  -Pplied  by  the  mueoia  "he 

■'  I  .".t.Min,-.  attor,ls  the  m,)st  p,.werful  proteolvtic  ferment  of  the 

;  ;-n  s  „;  .vheretore  it  f,>llows  that  arrest  of  this  Excretion    either t 

:      i-iatuHi  oi  the  .lu.-t  or  atn.phy  .,r  arre.ste,!  activitv  of  the  gland  celk 

...  Wed  by  UK.,.T,p|,.te  dissociation  of  the  protei,is  of  th/S   !„  j 

--im-nt  la.k  of  assnmlat.on  of  the  same,  so  that,  as  a  matter  o' 


591 


77//;  DicKsTn  t:  system 


fmt.  a  ,;„n.l,ti..n  nf  tru..  starvati,,,.  is  l,r„„Kl.t  al t  a.i.l  a  „n.ur,.ssiv 

-nar.at,on  ,|.-vrl.,,.,„«  .....r..  rapi.ll.v  than  fr.„„  ...v  ..th.T  ./hm 

It  al.M,  ,.x,rrt..s  a  li|M.lvtic  IVr....nt.  strapsin.  .^s.-i.tial  to  tlu-'  ,liss, 
<|«t.o„  ami  ,s„hs,.,„n,t  al,s,.r,,ti.,n  ..f  tl..-  fats;  int.Tf.rr  .,  vih, 
a  .S..K.  o  th.  ,.x..reti.,„  is  als.,  a  „ot....,  fa.,..  i„  tlu-  ..nL  i..:  .  ' 
nentione.!.  In  sm-h  cialitions  wo  fi„,|  that  tlu-  st.M.ls  an-  riav-colo 
from  excess  of  .H.altemI  fats.  Other  fernur.ts  are  pn^l  ,  ..  lot. 
an  am.vlolytic  or  stareh-s:)littinjt  ferment  ' 

this  orpan.  we  have  .hseusse.!  this  on  p.  104.  l,„t  we  woul.l  here  re.Vl 
that  there  ,s  n,  the  ho<ly  a  "sn«„r  eo„,l.i„.."  ,.r  "trnst.-  ul    vl  Ih      . 
panerens.  the  hver.  an.l  the  uu.scles  are  the  n.en.lu-rs   whi  h         tr 
he  amo,„,t„f  sn«ar  forme,!  an.l  its  .onsnn.ption  in  t  u-      1  i         , 
hat  atrophK.  or  .legen..rative  .lis..ase  of  th.-  pl.ncreas  is  ass..H       Ui 
the   .leNTlopment   of   glycosuria.     .\ot    all   .ases   of   .lial.ete         e  , 
panereat.e  eh„n,es.   ,.r  it  is  evi.lent  that  .-ertain  h-sion      ,      h     ot  , 
imallues  ""t^^^^^^  troIof;..;tt 

enco,mtThvno;i^^^^^        '"■'  "*  k  "'^'-    """"'""•  '*"*  '''  "^''"•^i-"  ."n 
enconnter  hypoplasia  or  even  absence  or  dupUcation    or    iir-ii..    .....r",. 

c;om„,o,.,,    the  presence  of  sn.ail  accessory  Iro^lt  pInSc  S 
ther  ,n  the  sni.nu.eosa  of  the  ston.a.h.  the  .luo.lemnn.  or  even  du  s3 
mtestuje.     1  he  n.ost  important  irregularity  in  the  .levelopm  -nl  «f    |  ' 
organ   ,s  n.  eonneet.on  with   the  ,l„,.ts.    'The  original  pa    ■  ea     w 

oS:n ;  oZ'' Air  '""'^  ^'r  ''""^ ''  -'"*••"'"•  ^-'"  tii; 'i;;.";',.  x 

r  nf   l  I      .     T'  ''•"■'•  «'""^<i'"'ti'>K  the  main  ,hut  of  the 

m^e,    w      in  't';:,^-  ,  '','  '^'\  T'""  "^  <i-.l..pn,ent  these  l.eeonu-  eon- 

ergots  .ltro,,h^.  so  that  mrst  cases  eventually  come  to  present 

only  a  snigle  ,luet  opemng  into  the  ampulla  of  \-at  -r.     In  10  pe   ee 

of  a     organs  examme.l.  there  is  persistenc-e  of  the  forn.er  ,luet  w  th  ,' 

hffieSth';  \^         T.'''''  •'•""'-"'"  -'^^ « ^---  • 

t\^lZ^.lT7r:^'^  'ts  co„,niunieation  with  the  main  .In.t 
fl !  ,1^    I        •  'j*-'.  *''*'  ""'"'^^  "^  obliteration  or  obstruction  nf 

n  lations  ot  the  duet  of  \\  irsung  to  the  commor.  bile  duet     The  two 
ducts  may  o,,en  mto  the  duo<lenum  side  l.v  side,  one  at  the    erv  tt^.nina 

TmrXs  .t  h  '^'""V"*'"""*."^'  *"  ^'"'  '•"'■  ''"^t  at  the  base  of  th'. 
i?s^  are  o     In    '  .^^T"t'"'^ter  or  more  in  len,,....     These  relationships 

0  the  amr .  m"  ;'"     ""'T.'^^r  '"  ''^'t^"""'i"«  the  results  of  blocka  . 

1  rdin?  H.  -r '1  :"'"'' ^'••"^t'''»-Vt<--  As  a  result  of  snc-h  blocka.. . 
cnt  r  .  n  "''"  '""^hips.  the  dammed  back  bile  may  or  ma^  n,. 
cnrer  tne  pancreatic  duet 

..nt™?f?;'*"!'*°r'-r''''"'  r'"'"'"^  '^  abundantly  vas,.„lnr  l,n, 
o»  account  ot  ,ts  natural  color,  it  does  not  show  to  tl„.  naked  ev,-  .„v 


Tin:  /'AXCREAS 


rm 


i.ark.Ml  (•hu„K,.s  .,,  an..tn.«;  .,.  .-asrs  „f  p„8iye  congntitm,  it  lK-c,..„es 
l.rKj..  .njc...,...|.  a,Hl  „r  a  l.l,.is|,.«rav  ....lor.  wlu-n.as  i„  activi-  hype«r. 
M...h  as  <M..,irs  .hiring  .hp.stM.n.  it  is  f,,,,,,,!  ,.f  a  ,,i..kisl,  n>U,r 

llH-  in..st  i.np.,rtant  .inulafry  .li.turl.an.r  is  thi-  sui>frv,.r.tion  of 

acute  hemorrhagic  pwcre.titi..     Th,-  series  ..f  events  I..«dinK  t.     E 
-y-  l.tum  IS  mm  Kenerally  H,knuwl..,lKe.l  t,.  I>e  ,  1)  the  .levei„prnen 
..     ocal  areas  of  .se|,e,„,a  ..f  the  Kia,..|  sul.stan.-e  !,v  arterial  ari.t  o 
-liM-ase    (J)  the  cells  >„  these  ar.N.s  ,„„|erK..  necrosis  with  the  lihera- 
.....  .nto  the  tHs..es„f  the  cellular  f..r,n.-nts;  C!)  hK-alizecl  ''if.  iLes- 

t.on  ..nsues  w.th  eros.on  „f  the  .apillari..,  a...l  oth-r  vessels,  asscK-iated 
".tl.  w huh  there  ..  ne.rosis  of  the  fat  ....||s  in  the  ..eid.Lorho.Kl  am] 

.  .s^o,-,at.on  of  the  .  onta.ne.l  fat  thn.UKh  the  aKcncv  of  the  liberate, 
stcapsn.  (fat  necrosis.  The  c.on.liti.,n  is  l,v  „.,  ,neans  ,.e!  Jarik  o 
.Mtect.ye  or.j;.,,;  arou.,.1  s„ch  areas  there  may  l,e,  it  is  trne,  evi.len.-e 
..  acute  ...flammafon.  I.nt  this  is  secon.lary.  Th.>  effect  of  these 
l.hcrate.  ferments  are  not  confine.!  to  th.  v.n.Teas  hnt  mav  invol' 
s..m,umhn«  t.ssnes;  the  c.m.liti,.„  n.ay  he  .api.lly  fatal  within  a  f.  ,.. 
I.m.rs  or.  on  the  ..ther  han.i,  ,  .re  are  ..vi.len.rs  that,  if  not  extensi  ■ 
re... very  may  ensue.  Mmai     , 

Inflammation      Thc-e  is  a  possil.ility  that  a  .■o...iition  si.nilar  to 

.-■  above  may  b.llow  a  lo.alizc.l  i„fla„.mati..n  in  the  pancreas  and  tha? 

..r,.  .s  thus  a  tr.,e  acut.;  .....Totic  au.l  heniorrha^ic  pancreatitis,  but 

I    >o,  bactenoloKical  stmlu-s  show  that  this  is  the  exception  a,i.    not 

.he  rule.    Purulent  pancreatitis  is  o,...a.io„alIy  encounter.  |ekher\4h 

m.hM.le  s,nall  pyennc  al-s.-.-ss..  in  .-as.-s  of  bacteriemia.  or  by  ext  ,.      n 

■    Thsr  "■■■'•  "*'"""7-  '  •  •  P«'''-*"'"-»^"'"  «f  «  ««^tric  ..r  ,luo.le„al 
...<.r,  .,r  lasth,  hs  an  ascending  .nflammati..n  of  the  pancreatic  .lucts 
Chronic  Pancreatit;is.-It   has  b.en  experin.entallv 'shown   bv  OpTe 
i'".l  oth.rs  that  by  obstru.-tion  or.  airain.  by  r.tro^rra.lc  How  .,f  bile  into 
.e  l.a„.Teat,c  .iuct,  there  may  .i.-velop  a  c.n.lition  .,f  fibrosis  around 
I. '  -lu.t  an.l  Its  bran..hes  due  to  resorption  of  the  secretion  as  well  as 
'.  h.  .rnt...t,on  of  the  ....•„„  fluid.     Whether  this  be  the  essential  ^au" 
or  no.  It  is  to  be  remembered  that ...  .-ases  ..f  cholelithiasis  we  frequently 
;N.->.".ter  a  marke.l  in.luration  especially  of  the  head  of  the  parreH 
ins  becoming  so  hrm  that  the  surgeon  is  apt  to  mistake  it  f.,r  new-g  owth 
II..  organ  also  ,s  apt  t..  show  extensive  fibrosis  in  a.lvancing  age  asso^ 
<;ate.l    with    the   chronic   periarteritis   of   arterioscler.,sis.^  We   £ 
.•roK..i/e  more  than  one  f.,rm  of  fibrotic  change  in  the  organ    viz    a 
ntnlobular,  an.un.l  the  branches  of  the  duct,  a  perUobularfsepamtbg 
"■  mdividua   cllections  of  somewhat  atrophic  adni  from  elch  other 

.  ' LiSn"'  T  T'^'  ^T'-^^"'"u'^^-^  *"  f'^«-"-  inflammation 
..icr.,Ms  of  localize.}  areas.     It  is  to  be  noted  that  a  chronic  diffuse 

iMcreatitis  or  cirrhosis  is  n.,t  infrequent  as  an  accompaniment  of 
•  'mosi.s  ol  the  liver. 

.^JaUvof!^-""^!""*'-"^^'""'^'""  '^  '"''-  ™^«-     A«  «  '•^«">t  of  con- 
^  nital  .sjphihs,  there  may  be  encountered  an  extreme  grade  of  diffuse 


596 


THE  DiGESTn  f:  system 


...t orstitial  i,a.Rri-at.t.s  with  ,  nlargomn.;  of  the  organ,  an.l  i.Hhiration 
an.l  pro„ou„ml  a  rophy  o  a  great  part  „f  the  panc-reatie  tissue  pro  e 
save  the  ishi.uls  ot  Langerhans.  We  are  indine.1  to  regar.l  the  isla.uls 
ot  Langerhans  as  the  ...other  tissue  from  whieh  ..e^^^ci,.i  mav  be 
developed  throughout  hte,  a,.d  in  this  and  other  forms  of  fibrosis  the 
pers.>tenee  of  the  islands  jn.lieates  that  this  vegetative  or  mother  sue 
IS  the  last  to  be  destroyed.  Others,  however,  it  must  be  noted,  rZd 
these  as  mdependent  entities.  '^gara 

Fio.  274 


Ii;i 


:i 


-  -.'^ •■'  I.-  i™,u,  p-nj;:;,,::r';;;;r : m^:'::::  r'.::;',::'': i'^j'™;""^"  '^'^  ^'"^ '""""- 

ar..  ,i,„il„rl,  ,,,,,,ratr,l  by  h  cuirilohular  fihro™,  ""Lvdual  anm  U)  in  the  lobul.-, 

J'Tr^u-u^T."-     ''r  T'  '"■  *"'^''"  *"  '''■^^•"^•"^f'  between 
nil.  tin  ,   -|>  are  i.i  an  active  state,  there  is  a  marked  tendenev  for 

o  ;^rm;,^s;"V"  '''rr^'  "■"'  '•-"«  aboit^rcSt^; 

L^mTv  beLn         ''     °°-  .  .'"  ""•  •'"'■'•^'  -^^''^''^  "f  ^his  proeess  the 
tC^:  nlS  '/:'r\"?''?^  "'"'  ""  ^^'''tio"  tl.e  nuclei 

aS-    i       n  !       .'';""•     ^  '"^  •'""•"*'""  "'^*'™bles  somewhat 

rS;'  ion      I      .^^        •'  '";■'"  ^^^^-'^'..-''t^ii-K  takes  place  with  dis- 
rgan.zat.on.     I„  ,  Iscussmg  the  so-calle<l  hemorrhagic  pancreatitis  w 
have  alrearly  described  the  ...ain  features  of  the  cmnn^rfo  ms 
ante  n.ortem  or  „.tra^•ita!  necrosis  and  .clf-.ligesti.,n.    TnTneraT  11 
attects  part  and  not  the  whole  of  the  organ,  and  areas  „rprSrvc! 


77/ A-  PAXCREAS 


r.97 


Oationi'  '?"'■'■'''""  ^''""  '*'"  P'"'-'^*''-^-^'  t'>^i^  "*>"nal  stdning  power, 
r  ;.     2  Vh  '"YT'"'  ;'t  "•-■•"tio,.  or  post  mortem  it  is  found  that 

K-  ..U.U  foe.  ot  fat  necrosis.  This  extensive  necrosis  mav  S^Tot 
"  m-lN  the  causes  above  mentioned,  namely,  stasis,  vascular  obliter- 
.t.<.„  ami  ,nect.on,  but  may.  as  in  the  case  of  the  late TrSent 

o;t';:s;;S:ir""'  •'^'  ''^^""'  "'--'-^  -^^-  -'^"  ^'^^^^ 

KegartlinK  the  relationship  of  the  pancreas  to  diabetes  mellitus.  while 
"  l"Htt.ng  that  the  matter  is  still  unsettled,  we  are  inclined  as  a  mltte^ 
<'  <'Iearness.  to  lay.lown  the  following:    (1)  i„  a  co,,si.le  ab  ™^^ 
"t  cases  no  change  can  be  observed  in  this  organ ;  (2)  in  the  raSv  nr^ 

orru'rhTn  t.r'-'  "/"r'^"  \^  M-pic  deg^neLtion^^X    la'nl 

0  langerhans  followed  by  atrophy,  with  little  accorapanving  general 
hbros,.  nt    he  organ,  although  there  may  be  considerable  Ttrophvo 

ab.S;  <>;•  ulZ'n? '   (Weich^lbaum);    (8)   the   slowlf  3i^ 
noiu  n    iV':""'*^''  ¥'  "^^y  Ije  characterised  by  marked  fibrosis  and 
:      ph.N  ot  the  organ  m  general,  together  with  changes  in  the  islands 

1  l..•^e  changes  are  most  often  of  the  nature  of  a  hvaline  deeeneSn 

M  (n.itic  acmi  there  are  data  favoring  the  view  that  they  play  a  nart 
in  till-  sugar  regulation  of  the  economv.  ^^      ^ 

tio'n  ^7n'X  *""".°^  '■^'K'-essive  change  in  the  pancreas  is  fatty  infiltra- 

lon.      „  adyancefl  cases  the  greater  part  of  the  glan.l  substance  mav 

I'.-y^'  atrophied  without  the  organ  being  rduce,!  in  size  a  f.ct  l  ^h 

|> .  ue  to  .ts  replacement  by  fat  cells;  oft'en  locali  Ja^e";  of  tch  f     v 

:       on^^n  •     '"'  '^T°"**'°"  "^  '^''  ^''^"''  «'"«  »'««  been  „ot«l 
Amv  2    ,n       I""r""'S-     !"**  necrosis  has  alrea.l>-   been   discussed 
Amyloid  change  is  to  be  seen  m  general  amvloidosis 

>mgle  or  multiple  calculi  may  be  encountered  in  the  larger  ducts- 
l->  are  forme,l  of  calcium  salts  with  a  mucinous  matrix  amraedi; 

P  ogressive  Chai^es.-Tumors.-^  We  rarely  encounter  benign  growths 
ld.ll '""•''•    /"  ""■•  '«»'oratory  XichoHs  has  reconled  locahm 

denomas  ansmg  from  the  islands  of  Langerhans,  an  n  Htn 
'•'«  -ther  smnlar  cases  have  been  place.!  on  record  (  thets  have 
-nl.ed  cystad^^^^^  representing  m.Ire  fully  <lifferentiate    pan  r^i 

'     a.   C  onnect.ve  tissue  tumors  are  rare.    The  most  important  tumor 

'  "XnSrr;    ''''^TY''^  '"?'*™^'-'  qullitLTo/r  h 

"TN  It  IS  often  difficult  to  say  whether  we  deal  with  a  primarv  nancre- 

7-  "''""""^y  ^"^-  ,f"-'r.  especially  where  these  ar'e  TPJ^Z 
-f  .=  pronounced  anaplastic  type.    Most  frequently  the  growth  origin: 


598 


THE  DIG  EST  I VE  SYSTEM 


rS-  I  •"'"u^  "^  ^''^^  pancroas.  an.l  most  frequently,  also,  is  of  a 
relatively  scirrhous  type,  but  soft,  adenocarcinomatous  growths  are 
to  be  encountered,  as  are  primary  tumors  originating  in  the  tail  or 
bo<ly  of  the  organ.  Growing  in  tiie  head,  these  tumors  are  peculiarlv 
liable  to  cause  obstruction  of  the  common  bile  duct,  setting  up  a  condi- 
tion ot  grave  icteric  toxemia,  accompanied  by  rapid  emaciation  when 
tUr/'Tr''*  '  ^*"'-":t'";'.  «>"!  t'xtensive  <lestruction  of  pancreatic 
,Sr\-  .If"'"'"'"'"  .'*'f  "  '»''*  *••  •'*'  t'-^tensixely  involved  bv  the 
nihltrati..n  of  the  growth ;  this  infiltration  is  :    t  to  extend  to  surrounding 


Fio.  275 


/f 


[77 


r^^^V*V    'S^-Tt^ 


tissues,  stomach,  adrenals,  etc.,  while  abundant  metastases  occur  in 
the  lymph  nodes  and  liver.  Primary  sarcoma  is  rare.  Secondarv 
melanotic  sarcoma  is  liable  to  affect  the  organ. 

Multiple  congenital  cysts  occur  along  with  simiSr  cvsts  of  the  liv.r 
and  kidney.  Retention  cysts  of  later  life  (ranula  pancreatica)  mav  l„ 
either  solitary  or  multiple,  may  attain  large  size  an.l  are  due  to  obstnu  - 
ion  either  trom  a  c.mcrement  lying  in  the  main  <luct  or  one  of  tl.r 
»)rancli.-s  or  .se<-ondary  to  inflammation  and  obstruction  of  the  duct. 
Ihese  cysts  are  most  often  in  the  tail  or  bodv.  Echinococcus  c\-t> 
are  recopiled. 


CHAPTKIi    X 

THE  URINARY  SYSTEM 
THE  URINARY  FUNCTION 

General  Considerations.-Einbryology.~The  permanent  kidnev  ap- 
[.tars  about  the  hfth  week  .,f  f.etal  hfe.  and  i.s  made  up  of  cells'from 
he  U  olffian  duct,  on  the  one  hand,  and  the  mesoblastic  tissue,  called  the 
Lh^tema,  on  the  other.  The  former  gives  ,>rigin  to  the  ureter,  pelvis, 
cahces,  and  collectmg  tubules,  the  latter  to  the  glomerular  epi  helium 
an.  the  rest  of  the  tubule.  This  complex  originlnd  close  relationship 
t..  t he  prmitive  myotomes  suggest  a  partial  explanation  of  the  frequency 
with  which  mixed  tumors  (teratoblastomas)  appear,  and  appear  too 
...early  life  The  fact  that  the  Wolffian  body  and  the  geS  gland 
arise  from  the  same  primitive  genital  ridge,  explains  why  developmental 
an.,i nahes  of  the  kidney  and  the  reproductive  organs  ar^  so  apt  fo  occur 
tcftctiier. 

Anatomy.-The  renal  arteries  are  short  and  readily  allow  a  trans- 

erence  ot  the  aortic  pressure  to  the  kidneys;  the  kidneys  are  relativelv 

.  I'.  ...lantly  supplied  with  blood,  and  theoretically  all  the  blood  in  the 

"Hly  may  pass  through  them  in  a  short  space  of  time,  ^he  result  being 

tli.  brunt  of  It  in  full  measure.  When  they  are  damaged,  the  other 
Mrretory  systems,  the  skin,  the  intestines,  and  the  lungs  must  assume 
tlu.  responsibihty  for  the  work  which  they  can  no  longer'accompS 

sns  vntnlll'T'  ^Tr  ""\*  ^r.™"*"^  "^'•ves.  and  are  therefore 

n    .pt.ble  to  central    .   ,         pheral  impressions;  the  effect  of  mental 

.■s  upon  the  amou  .nne  is  well  known,  as  is  also  the  reflex 

;.!!;,  ;,;;,™.  "''"  .mumcatd  from  the  bladder,  genitalia. 

nJllli.ll'r'''"'*'  "^t''l^'^«'"r^•  »«  «  plexus  of  unstriped  m..-le  fi'jres, 

M  racf  on  and  relaxat»»n  to  promote  the  circulation  in  the  kidnev  and 

.^^•  mochty  excretion.     Their  anatomical  position  in  the  My, 

1  the  peritoneum,  protected  as  they  are  by  abundant  fat,  ensur^^ 

'IK  kidneys  some  immunit>'  from  trauma,  while,  on  the  other  hand 

; -.nunica^jg  ,n<hrectb'  with  the  outsi.ie  of  the  bcniy,  they  ^  S 

'    "  rtaiii  extraneous  infections. 

I.   '"'mtf  !°''T  °'  *''*  ^™"-y  Function.-  It  is  so  usual  for  a  gland  to 

..I   internal  as  well  as  an  externa!  secretion  that  we  are  tempted 

'     ""«l'.'le  by  analogy  that  the  ki.lney,  whose  main  w<,rk  is  obviously 


i:3c' 


000 


THE   CR/XARY  SYSTKM 


i-i!  } 


ru'loinic  cuvity  int..  a  ti.bule  which  passes  to  th„  f.i  < 

r„  t„l„l,.   t,H,,  ,  ,r„„Bl„.ut  its  l,.„Ktl>.  L,  in  ,„,im„„.  „,,„dS,  "    1 
hi.  Ivmph.  „,„,  winch,  „„„!„.  the  .lin-ctio,,  „f  «„„■  i,  t,^^  the  tub  I  » 
*..„«  t„  ,„.  „„t,i,h.;  ,«  „,„  e„tip..l.v  so.     We  must  rrnlZ  ,h 

^:tn:;;,:'c'^h;;erz,:':-i  t^r:  r^£^ " 

The  VmcUu  Suppl,  of  the  Kidnej.-The  arterial  supply  „f  the  cortex 

r  o'  K?!;  ta't^l"":?  ™'r*' "; ","  *""™"-  f '•e  '""^  -  - 

u.e  Monitri  luh  in  the  afferent  \essel,  leaves    t  in  the  efferent  vessel 

;  l^f"^,^^*^S1,'"r '  "T"^!^  1  ^^'^'''^"-  al^lS'lhV::!: 

m.T,I  .  V  >  ^ '""'  '"''P'-''  "f  t*'^  collecting  tubules  in  the 

medulla  is  from  capillaries  of  the  arteri,e  recta..     The  bhlT  sunnk 
of  the  cortical  tubules,  having  been  through  one  set  of  ca    llarie  Tl  e 

'.  tt    1  •    7u        .?^  ••  '""''■  ^  ••^''*'"-pt'<»»  from  the  urine,  which  is  not 

tn  u    '^1'  ?:  '""V*?  *"''"'^«  ^^•''"*'  th«  Woo'l  pressure  is  hdu 

An    in  all  probability  this  is  what  actuaUv  occurs.  *' 

I..0.1  pressure  determines  to  some  extent  the  .lischar^e  of  urine- 

rit  srs  irrr '"  r:-"?'  *" ''  '"'"•  "^'  — '•>^  '^e  a""":,- 

Z"  is  c?  mo  .  7  "■"'"*':"'''■  r™"'  renditions,  the  rate  of  bho.l 
mc.ldtir..'^''  •'"■'■  *''"';  *''"  P""^^^""'  •"  the  glomeruli.  U- 
■e  s,  c  ""  '""''''  '"'*'  ^""'^  *'"•"»''''  ^""P'^  ^•'""'t-'O  «'"' 
gl  menir.,  t.  .  ^^T-'r "*-'"''  "^■"""P'"'^  the  water  through  th,. 
tear  ^^■';''''  ^"'"''  "''^".•n'tion  occurs  in  the  coni)lut..,| 

.  t     tlu.    .r  *•"""■'"'"  '""T'  ■'  '^'  ^"'•t''^'-  «-'«'tive  excretion 

mto  tlie  urine  ol  urea,  uric  acid,  and  other  "extractives  "  as  well  •!> 

s  W^^^^^^^^  H   '  "'•''"''"■  ""^  '^"tabolic,  of  which  the  result  is  al., 

ThrNe,lrSuni"'TT-^     'ts  way  through  the  convoluted  tubni,. 

to  tlu  L??       Supply.-^ -This  IS  of  considerable  complexitv;  the  ner^  ^ 

to  the  kidney  form  a  plexus  around  the  renal  artery,  ami  are  for  the  in,. I 


-M 


THE  VRISARY  FL\CT10\  (jqi 

I.an<l,  be  ^Sorv  "  A  r  '  r^.T  **:"""'f  "'"^  "'"«t.  .».  the  other 

the  quantitUf  bZdXwinl  :•         L**!!  "^r"*'*'''  "^  """*'  "I'^P^'"'-^  •>" 

!l.<'  venou;;Lsll;:e";:"^£--^----^  --ase  in 

-n.rease,!  without  increase  in  tL  arterTaMes     *' wlu"""-^  '^T"''  u' 
>!/<•  of  the  arterial  (•hai.i,».I«  ;„  //    7 . ,    "''  '*^^^-  ,  -^t  t»i'  same  time  the 

tl-  urine  is  a  onK   v^h"  "S"  '""*  ''\  ''^''■T'  ««'"""*  = 

n.ised.  but  even  if     vit    ..  t  ■  ^    ^''"'''■"'  '""*•''■'«'  P"'s«i're  is 

int.rh,buh.r:;:;^'L        "  ir^^^^^^^  ';'rl   pressure,  the 

interlobular  and  afferent  «rt;r7  f       '  ','"  *''^  contrary  if  the 

'-.:^..era,pre::,^^;h:l:::::;;:^  ^-ation  of 

-paratefrc.mitrblneesth„t«r     ^  ^'  ^™^""*  "^  ^"^'•^-  «»"'•  «■«'  *« 
« In'l.  are  br"  iX  Tf X  i-n"*  "f  unnecessary  or  actually  <letrimental, 

"'•    kidnev  Villi  1   ititXin'.  ^'  '''T'^-  u  '^^''^^^  '''  ''^'^'^^  '»' 
"tl'.Ts  nietabSed  a  ui  nT^  •  ^  Passed    others  retained,  and  vet 

^^--.atio:i---r,^^ 

'•n  ret"ion!fri"°°'~'^''r  '"'^•^-  ^'^  ^''"-'--'  ""d-  the  hea.ls 
'it^:>>^tL;-i        '•''"?"'  '"  r'"P"«ition  hut  abnormal  in  qua  1 

•""-1  in  the  ur  n"      Such  a  l.V   -"''r*'""  "^  ^"bstanees  not  „o;-mairv 

:..  urate,  becau      tlu^i.nn/  •    '"-'"'r'  '^  '""••"•^' ''  vsiologieallV 

'  the  .n,ttT      «>!,?" Its       H^T'r  '•  ^^'''''^  ''>'  '^^  ^""^-entratio;. 

'  i :  u.av  be  bro„.,ht  M  HM^;  M  ^        '^''T'"'*^  *"  '^'*'"*''-«'  Princinles 

'''■•Hit  renal  chmle   o    n     iinTJ""  T  *''''  f  "^''•"'  «'-*^"«'  P''^^^"^^ 
cnangt,  or  (-)  dilatation  of  renal  arterioles  without,  of 


602 


THE  VRISARY  SYSTEM 


V 


necessity,  any  rise  in  general  l,l,.o.l  pressure.  (;})  T«  tliese  it  is  obvious 
that  a  third  factor  has  to  l.e  added,  namely,  the  effect  of  certain  salts 
and  other  substances  upon  the  secretory  epithelium,  stimulating  it  to 
greater  activity.  Diuretics  may  act  in  any  of  these  three  wavs,  and 
some  of  them  in  different  ways  at  different  times,  or  even  in  more  than 
one  of  these  ways  at  the  same  time. 

Decreased  Amount  of  Urine.  OUguria.or  Anuria.-Heduction  of  urinarx 
flow  may  be  caused  by  (1)  lowering  of  general  blood  pressure,  (2) 
direct  contraction  of  the  afferent  vessels,  or  (;i)  increased  venous  press- 
ure; two  of  these  may  be  included  in  the  more  general  .statement  that 
a  red!  •  n  in  the  difference  between  arterial  and  venous  pressure 
leads  .„  oliguria.  To  be  adde.l  to  these  is  (4)  any  obstruction  to  the 
urinary  outflow,  i)rovided  it  affects  both  kidnevs.  The  oliguria  that 
IS  so  marked  a  feature  of  acute  nephritis  is  probably  due  to  the  amount 
of  glomerulitis  that  is  present,  rather  than  to  the  effect  of  swelling  of 
the  epithelium  and  consequent  diminution  of  the  tubular  lumen,  although 
this  IS  often  pronounced  and  cannot  be  whollv  neglected 

The  Soli<b  in  Urine.-Some  of  these  are  the  product  of  the  ordinarv 
processes  of  digestion  and  assimilation;  some  are  the  pnKiuct  of  normal 
metabolic  processes,  others  ..f  abnormal  metabolic  processes;  some  are 
due  to  extraneous  agents,  such  as  bacteria  or  metallic  poisons.  The 
following  IS  a  list  of  the  more  important  substances  found  in  the  urine 
s  -ne  of  them  only  in  minute  quantity:  acetone,  achroglvcogen,  allan- 
toin,  carbamic  acid,  chlorides,  cholesterin,  chondroitin',  creatin  (») 
creatimn,  diacetic  acid,  diastatic  ferments,  glucose,  hematoporphyrin! 
indican.  isomaltcse,  lactose,  mucin,  nucleinic  acid,  nucleoalbumin, 
orthocresol,  oxalic  acid,  oxaluric  acid,  paracrcsol,  paraoxvphenvlacetic 
acid,  parao.xyphenylpropionic  acid,  phosphates,  pentose,  pi^ents, 
proteolytic  ferments,  ptomaines,  purin  bases  {'!),  pvrocatechin,  sul- 
phates, urea,  uric  acid,  and  volatile  fatty  acids. 

Ure.^  —The  excretion  of  urea  depends  on  (1)  the  ingestion  of  nitro- 
genous foods  and  (2)  the  breaking  <lown  of  the  organized  albumin  of 
the  bix\y.  Ihe  amount  eliminated  in  the  urine  of  a  healthy  individual 
on  a  mi.xed  «iiet  varies  from  20  to  45  grams  .laily.  The  quantitv  is 
increased  m  febrile  diseases  and  decreased  in  malnutrition,  as  well  as 
m  disease  of  the  kidney  parenchyma. 

Uric  Acid  —The  daily  excretion  of  uric  acid  in  the  healthv  adult 
varies  from  0.2  to  1.25  grams,  an<l  is  derived  from  the  katabolisni  of 
the  nucleins  in  the  fo..d  or  the  body  tissues,  so  that  whenever  there 
is  a  h)ss  of  tissue  albumin,  as  in  fevers,  its  amount  is  increased 

KKATiNix.-  The  daily  excretion  of  creatinin  varies  from  O.O  to 
1..}  grams  derived  from  a  diet  of  meat  or  from  the  muscular  tissur 
ot  the  ho(  y.  It  IS  increased  by  bodily  exercise  and  in  fevers,  and  i^ 
diminished  in  many  diseases  that  produce  a  cachectic  state. 

Alblmix.-  \  arious  proteins  may  appear  in  the  urine  unchanged  from 
absorbed  focnl,  as  egg-albumin  after  an  excessive  diet  of  raw  egu- 
or  as  mucins  or  nucleo-albumins  from  tissue  disintegration;  but  the>t 


ALBCMIMHIA 


6a3 


....   .nfrequent  am    unimportant  compared  with  serum  albumin  and 
s.;n>m  globuhn    which  are  the  bodies  c-oncernod  when  we  sZk  "f 
...  n.nurm.     They  are  the  dominant  proteins  of  the  bio  k1  Sasma 

k.K-  ttat  when  thT;v^'^'•^?r«^**'^  «'«'"^"'"-  •»•*■*  '-^  «'- 

I    -^  .^'it-n  the  tubular  epithehum  is  disintegratinij  the  albumin 
sj.  .lenved  ,s  added;  further,  when  the  tubular  eF^theli.m     s  ^st T 

lu  tubules  Thus,  m  h  severe  acute  nei)hritis,  it  is  likelv  that  the 
tubules  contribute  a  considerable  am.mnt  of  albumin,  while  hf  the  miller 
.ases  the  glomeruli  allow  the  albumin  to  escape.  The  .li^^inteJItT  ' , 
..Is  IS  not  necessarily  accompanied  by  the  presence  of  albuS  n  le 
n,:.-  K  «bumm  found  m  urine  is  usually  serum  albumin,  bul 
^  may  be  globulin  alone,  or  with   mere  traces  of  serum  albumin 

TZ^STi^-TZ^r^'  '^'^^  f'-™*  "'  «  -"sta't  ratio  to 
j,i..i)umi  of  .i  to  J  and  globulins  are  the  more  diffusible  these  facts 
s..™  to  indu-ate  that  the  glomeruli  have  a  power  of  select .,, 

Physiological"  Albui^urla.-This  is  the  term   used  to  designate 
H  appearance  of  albumin  in  the  urine  in  those  whose  suSuent 

..count  for  It.     It  may  appear  after  cold  baths  or  violent  exercise 

lo  th^t:^'^^  '^ ''-'-"'-'  ^^  ^^'-  ^'^-^^^  frorjh:™:^ . 

Cyclical  Albuminuria. — This  is   nr.twl   ;„   +i  ■ 

:;i;  i:rSi:LfL"!r'""-  '*  •"'■'■  -«™  *-  »■»''-- 

ilbuMMrt.  ftom  Olr(!iJ.tor,  Dtatotanc-Wlmtever  slows  the  rate 

.  ri       Tht"      r".'!  "'%''';I"'J»  f"-»»  the  .ppearanee  ,f  albuiS^! 
un.i.     ihus.  contraction  of  the  renal  arteries   n^  ;.,  l»o,i  .    •       .      "" 

-js  obstructions,  as  in  heart  dil^^^^^^  ;^ '^  .^ST  K 
ruMl    xein.    causes   albumuuiria   with    lessening   of   the   amount  of 

Toxic  Albuininuria.-Many  mineral  and  bacterial  poisons   and  the 
.known    oxm  of  eclampsia,  are  capable  of  causing  a  buminuria 

Infectious   Albuminurla.-This  is  exemplified    bv   scarlet    fever   and 
;      't.K'..c.cus  infections,  and  is  especially'  due  to  i;sion  of  the  glomer' if 
abundant  discharge  of  albumin,  and  sometimes  even  of  bS 
"I  "soles  the  parenchyma,  too.  is  generallv  damage.1 

1^  'Sr;7n  ot"c!|;;"^^  '^'""J".  *'"  "^"^  ^^''^""^he  intracellular 

'"sm  of  proteins  is  perverte<l,  as  in  tuberculosis.  suDDuration 

;     '.rus  poisoning  and  osteomalacia.     Bence-Jones'^SE        a' 

^A      IT  '^'?.'."'  '"  ''''^*'^  °^  ™"'tiple  m^•elo,„„s. 

Hematuria.-   Blood   may   appear   in   the   urine   from  causes  in  the 

I-  '"■>  ..r  elsewhere  in  the  tract;  it  may  be  evidenced  by  a  Zk  or  bright 


^1 


H     i 


604 


THE  I  HlX.un-  .S'J-.sTA'U 


Hemoglobtauria      II..,n,.Klnbi„   ,li.ss„lv.-,l   i„   t\w   nri,,,-   mav   a,,,,, 
«l.en   lK-n.olys,s  has  ......urnHl.  tlu-  material   bt-i.«  a.f  ,dh    s  c 

and  ii„t  filtere.!  in  a  n»-<lu.nical  wax  • 

DisturbRiJces  of  the  Function  of  Urination.    TI.e  iH>Ivis  ,.f  the  kidn 
".1     lu-  rrotcTs  are  merely  an.plifie,!  conchutors    >f  t  e  n     .e      T 
;'r        '  ""'V"';.  -'t''   ^•"-•tio-al  P.>-er  ..f  .liseharge      The    I 
nd  .(.tnuH  '■"'"'•'^•*"f  "PJ'"'-»tus  are.  therefore,  ehiefly  ..bstructi 
.ind  ..l,.tru(  turn  may  arise  in  a  variety  „f  wavs;  it  mav  result  f r.  m 

I  tn.m  shar,)     k  nks     m  the  tnhe;  (2)  thickeniiiK  of  the   vails 
""""::;;"•""'''  'T'"'"''^  J.yper„Iasias:  (.)  pressure  f,!" J     i,, 
«  .r  1    "'"7^- .'""'"*'''•  '"■'-'""■'^  mi^plaee,!,  traction  or  pressure  , 
ft  r  ,us  l.an.ls.  |,«atures  an.l  so  o„.     Fim.Ily.  the  same  ultimate  resu 

r: ::;;:;"  soiut.o„  of  o.>ntinuity  .,f  ti.;  tu...  so  that  s;::s: 

whXr  o  e     ;  U.   uf7    "^  ^'''^  ^'^"""'^  obstruetions  .lepends  upo 
wmtler  one  or  both  kidneys  are  concerned;  mo.lerate  obstrictio. 

Tc^S;"  ^'th-    '|^'-*-P'>>7''<-  the  point  of  obstruSn 
.M^.e      «       1  i    ,.  ^  d;""""t.<>n  of  urine  by  the  employment  of  mor 
ont.     iJut  this  cannot  k'o  on  indefinitely;  the  extreme  of  hvnertronh 

Magnation  of  the  urine,  an.l  s..bse,,ueMt  infection  thus  n-sults  aTl "m 
an  infectiou  may  j.roRress  upwanl  to  the  kidnev  itself      A^a      fm 

iiaur.  I    the  other  kidney  may  compensate  entirelv  for  the  lack- 
but  it  bilateral,  uremia  and  .leath  may  quicklv  ensue.  ' 

uri  I'l'ti,  n      Wer,''.;''";';'"- ■  rrriT^   '"   '•^«"''»^'"*''  tlu-  functi,.,.  of 
^"       .^  but  i     /    '"        ■■  "•'  '•'"''''7'  *''^'  ""•»'  ^^""'•'  '^^'  ^ontinuailv 

nusde  wh    '  ;i  /  '.""•^'"■"i'">-  '*  '"""^'^t^  "»■  t^^"  ^•l'''n«»ts,  a  sphincter 
he  .tiono»^  :''/'■  "'"'  "  '^''W  "^"^'•'^'  ^^•'"'•h  -^x-ls  the  urine: 

ch  1,  i  ab .  tn  '^TT"\  "  t'•^''''"^•'^''••  I^'-'tor.  by  education,  tli. 
Se.  cen  ^o  ".iitrol  an,  time  the  function.  There  is.  therefore.  :. 
cord  ?  a  ^  'f  1  '"  *'"  ^>"»irt''-t'^  -^vstem.  not  in  the  lun.h.r 
nmscle       i..l  ri  """'?■     ^^"^   '^'^'"''''''''   '"'•K'^'y   «♦■   voluntarv 

rrth;.i,mr  T  """''•'  "'•'  r'"'*'"-'^"""^  urethra  to  fill  with  uri,,;., 
an,  he  1  np  ilse  becomes  irresistible,  the  detrusor  expelling  the  cent.-  : 
ot  the  bla,lder.     Factors  which  govern  the  reflex  irritability  are  ti.e 


KIDSHY   I.KSIOSS 


(iO.J 


•Mnonnt  ,.f  .listension,  the  state  of  the  mucsa.  an<l  the  ehar.eter  nf 

tlu.  kidneys,  siK-h  a,  art,Tio,,*r„»is  or  a  weak  heart  in  ,  d, 
i"l  "thers  causing  an  ii,oreose<l  retention  „t  blood  in  tlie  o?eanT  ™  h 

i;^     rC;r"l",h'°"'-    ';■  '"i."'  "■-""•"Ps^.lSi'  u,   t 


,,.,„„.      ,        — --  ■''■i'>c  Lu  hueii  innuences.     Ihe  vasomotor 

-       n  t'ZJ^  T^r\  '''^*=-  ^."^^^"^  cleviation trX 

n-  more  important  is  the  quality  of  the  blood;  it  may  be  vitiated 


CifXi 


rilK  VRISARY  SYSTEM 


i^ 


b>   the  toxins  ofhutona  or  l,v  rhomiral  poisons;  hacteria  mav  » 

entrance  to  tl...  k,.ln.v  or  n.a.v  .lamaRo  it  l.y  tlu-ir  toxins  prcKlumi  d 

^here  m  the  ImkIv.     Kven  the  pr-nlnets  of  putrefaction  in  th„  L 

mav    1h.    potent    eanses   of   damage.     Substances  that  are  norma 

excrete.1  l,v  the  sku..  th.  hn.Ks,  or  the  liver  may  In-  thrown  "^ ^t 

kidney  u.  states  of  nicomi)etency  of  those  organs.     Finally  the  kidne 

may  Ik.  damaKe<l  by  the  action  of  substances  the  result  ..fLrvS 

metabohsm  such  as  «p,H.„rs  t<.  .K-cur  in  eclampsia,  dialn-t  VmSlm 

and  other  ill-understooil  states.  .  mA.i.ierr 

While  we  group  many  of  these  disease*!  states  under  the  gene, 

nX'"^    f '*^*^  '*  ™"^'  ^"^  remen.lH.re<l  that  we  have  two  .ifi^Je 

orders  of  phe.omcna- degenerative  and  Influnmatory     The  former  I 

man,fested  by  retrogressive  changes,  such  as  cSiv  I^  I  h  g  It, 

degeneration,  vacuolat.on.  and  necrosis  of  the  secreting  cells,    he  lat 

by  congestion,  exudation,  and  hyperplasia  of  connective  tissu;     We  a 

preparefl.  also,  for  the  coexistence  of  the.se  factors 

The  bfluence  of  Kidney  Lesions  on  the  Excretion  of  Urine  (ire, 
latory  disturbances  and  other  abnormalities  thus  affect  the  secret  n 
structures;  le.sion.s  of  these  structures,  in  turn,  moclifv  the  combos!  o 
of  the  unne.  and  the  systemic  metabolism.  The  urine  is  thuXefle" 
tion  of  the  state  of  the  ki.lneys  and  of  the  metabolic  processes  of  th 
bo<ly;  we  therefore  find  in  it  deviations  from  normal  in  pointTquantitv 
specific  gravity,  and  reaction ;  in  the  appearance  in  it  of  abnormal 

m't'saUs  a;;d  h '7"''  "TI  ""■^•'  P"^'  ^P'^^^"'™'  -sts  ",3  pi 
const  tuents.     These  can  be  referre.1  to  only  in  a  verv-  general  wav. 
Acute  Parenchymatous  Nephritis.-The  amount  c  f  urine  is  great h 

L  ul;T  .,    ^  ^Pf^'fi^g'-«vity  may  be  1025  or  1030,  the  urine 

..turbid,  generally  deeply  colored.     It  contains  a  large  amount    .1 

enaun;rv  rr'  T  T'"'' "'"'"''  ,^""^'^^^  "^  ^'^^  -'^'  2"*;: 

Tastsof  anvo  HI  '^'f'^T\"^'-'''^'  "!  ""^'  «"^'  ""^  oxalates," and 
of  crvoLn^v.  '  T  ;,  ^*'  ^'"."^  ''"'"*  (determined  by  the  process 
a  h  morrl.«i  '"«t'V*''»'!  that  of  normal  urine.  In  the  form  know,, 
Lutrinfi;?v  ■  '"Pf  ■■  V  •  ^^'r'  '\P"''*'"'  '"  considerable  quantity.  1„ 
kdnev   I        •      '"mT''  ''■*'"'"  h"^"**""^  «'•«  ^^tually  at  work    n  th. 

SctU^iZir^^  '^"  '^"'^"™"-^' '''  ^"™^  ^' '"  ^--'^^«-  (- 

ere^ln,?**"^*^*^  Nephritis.-I„  this  form  of  nephritis  the  urine  ,s 

Kmo  1  m -r  ";,'*'"«""*•  ^^■"''  P«'«  i"  col'T,  of  low  specific  gravifv 

abSnt      S'  '"  r  .P'"'?^  '"  ■'*'"*>"  """"""t  °^  ™«y  even  h- 

P~L    r!-  "'^Z'"::' «"d  t^e  «olids  generally  diminished. 

arc  .!r.fm      ""':"""'■  .'^.'^''■i^'  """^'^^'  ^^'t^''  epithelium,  and  ,.us 
the  ?^in.    If  ir'"- =  'Y  ^'°."*'  "^  **  ^^^«  hemorrhage  may  appear  i„ 
the  ur.ne;  if  there  .s  ulceration,  shreds  of  tissue  dso  may  bT^r.- 
llie  causative   bacteria  may   be  demonstrated   in  the   urine.    The 


THE  KlhSKY  ,;j)- 

tl-  l»-art  had  ti  work  hanU-     o  ".roMJ.  l'"''.'  '  ""  "'*"."  ^"^  ''""^''^  *''«* 
it  is  prohably  more  '    ^Jto  ^uml^   ir  h  T"^-''  "«  '^'■^'"*"-^"'  '"'^ 

in  part  are  the  .n.'.st  salLl:;  o  rj  ^k^r^fw  "'5^;.";:^^^^^^^^^^ 
MHi,  can  be  excrete.!  hv  the  skin'-  a,.,!  th    ;      .'.\!'^'»''V"'*'  very  httle 
tn,ti„K  the  toxic  materials  1,1:  b     -  ,n  ^"',"'1  V  T"'^'-^  "^  ^••"«''>- 
>'^  the  ski,,  so  that  ure.,Ji;^l^\n^,^,'"^:  ;;"■"'  ^-P^  'f  -ater 
I'nm..  to  occur  ••,-    |„.  ;„testin„"l  fr-,  .f  i,  •        "''*''"»f«"'"^  that  are 

•'■"",o„ia  from  the    rJ^  eu-  eti^  '"H-phr.t.s  are  probably  ,h.e  to 

i-t.Tial  activity     """  *-'^"*^"*'  '"*"  ^^e  tract,  assistt.l  by  increas.Hl 

^^^'^t^^^^tS^  consists  of  hea.,- 

^^>teIni,HhVate.lbvconv,      on«'r  •''^t'"-'>ance    of  the   nervons 

t"xic  eHect  of  all  the  1,1         ••       "'.^a^^*^  »«  ""t  yet  kn.nvn;  the 

-Hi;ient  ^>ti:^fj;'r"iS^i'  tfx^  r""'""'  /^  •  ^■'^^^^'^ 

^"  the  toxic  effects  quickh-  orrKlnc ««  h'  '      "  •""""'at'^e,  and 

|-""-i-     IVrhaps.  L,  Z  SS^ti    u^XrrCi'l"*  ^^'^*?^' 
''^iN-  certani  toxins.     The  work  of  th  '  J  V.l         i  •'''*'  P"'''^'*"  "» 

'-  "ot  yet  sufficientlv  known  ^''''  *^'''         '"  *''c«^'  states 

)i'''ity,  so  that  the  s  bj  it   o^^^^^^^^^ 

'"•  ■  ti.ms  of  all  sorts  ^''"^'""  '"■^"  ''"'''*'  *"  ^"«'"mb  to 


«;as 


77/ a;   r/.VV.iA'K  ,s) 


K\f 


THE  KIDNEY 

wit?I!f*f  *^  Abnomulities.     Absence  of  h...  |,  ki.ln, 
Mtl.  I  tr.  I,„t  al,s..„,r  ..f  on,.  I„,>  |„  ,,,  ,,,,,  j,,  „„,„„„ 

n^httm».s.     It..s.sai,|.|.„„,.v,r.„,.,i„.„,,M.«sVc 


of  tin-  ki.liH.y  has  i„.  iH-aririjj  i,|h.ii  tlio  a  I 
oftfti  a<(„,„,,a„i,.,|  |,v  „|,s..„.,.  „r  anutiu,! 
I  u'  nret.T  n,,.y  l„.  ahsont  „r  a  l>li„.|  im-Ur  „ 
llw  siirKical  itiijx.rtaiuv  of  unilateral  kidr.ev  1 
r.-...ov,„K  a  ki,l,a.y  tlu-  prcs,-,..  .•  ,.f  tlu-  r„   .  r  ,..,„. 
the  wnttT  n-ralls  an  c.,-,,,si„n  on  wl,i,.|,  oL^,    .„.,,  „ 
the  siir«..on  from  r.-in<.\  in^  th.-  onlv  ki,ln,v 


of  i; 
ill- 

t:    t 

nine 
I 


•ys  is  not  <.«)n.sist«' 

autopsy  (xjH^Ti*-!! 

■art-ful  fxainiiiarii 
y  tissii.-.  Ahst-n 
«•  same  M(|(.,  I.iit 
k'l'iiititl  -triKtiin 
'  into  the  [)la(|(l, 
'■  '■  nil.  that  l.*'fo 
nnst  !)»'  vcriHiH 
Hi  -  mil  'ircNcnti 


m. 


Fio.  277 


*^iinKiniiMl  (•' 


>»ii'   liiclnf\ 


S.'<fi„n  ,1,.,«,>,K  muliipl,.  ,.y„>  „(T.-ciMiK  I,  .>l, 
i.MHiill     I'lih    Mu,., 


'irlox  :in,|  in.. 


Anomalies  of  Shape.     In  ,„,ilatoral  al,s<M,«.  of  tlu-  ki.lnov   •!„.  .;„„,, 
kHln..y  pn.s.„t   ,s  ...urally  lar^.T  than  .M.al.  an.l  .  ft  "/'.ui    ',f 

ol  th.   ki.liic,  ,  which  ranK.-  from  that  ol.s.-rved     ,  an  Mr.r-.M  th«f  Z^ 
sM.  ly.  to  that  s..n  in  a  ki.ln.-y  which  n.av  he  ,..1"  2^  l^lft 

Tn  ml!^^^  ™""'*'""  '"•  -"♦'    ■  ^•"  '■  «  l<i'!".-v  posses. 

a  niimt)er  of  tinn-walia    ivsts,  often  reinfor,,..!   I.,    lih.       \- 

cntainin,  lin.pi.l  flni.l.     They  n.av  he   ot   ^   it e' ,.      ^^^^^^      " 

Circulatory  Disturbances.- Anemia  -\ne    "      ^  thl  L" 

part  of  a  general  anemia  affectin.  all  .^,a;^:n.      '  ^^  f^^^^;, 


rnh:  kidshy 


m 


■irMi  Its  J.   .iiifr  ili 

"H«Js     .,  "cFMBttc 

■■I,  ■ 
all 


tS 

in  a 
tie 
•  an 


tenii 


'"H^ir  "7!  """'"'•  ">"■  ^^^^^  rr  ■  '^  ^  "'^'"* 

'  st«tr    -affairs  that  .  .nnot  ea.lv  ,     ,Hff;re,    iat' 
^'VKor   ,t..r  nephritis;.   f«,,.  ,.•«,.    av.  sTa^.f,",,. 
.>rn„  nml  for  such  .liff-rentiation.  ...  o.rc^la,  ,' 

Thrombosi8.-The  arterie  or  ti  *'    ,  i„    .,f  th 

--.I.  most  often  as  part  o-    ^^  n^^nif,-  ,uZ 

'l.nth  does  not  ensue,  an<     ,..«,«.-,       H    ,' 

EraboUf  n,.-  En^  ,oh«n  of  the  renal  artVv  r 

inlarete,!,,,  ,t,,.ntiret>.     Ex.         in  th' 

•ri.MH,Klohmn  theurin.a.,,ltem,M>ra 
';^il^  vuth  the      Himtion  of  a  depress 

Inflan:?tiation. 

'liiit  .-rv      sijfiiat 
file  char    *■«  ar< 
^nr>'  to      -eomp; 
III  ulii,.!,    iiechai,.- 
intccii      Ik  uinning^ 

''  "-     U>  said  tha 
t'iitliulujji  f  is  necessary 
;f  till  pat     Insists  had 

''-  -  er,     -ified  thTnrrWrJth"  In .;"  Th '  T  "'  '!"'  ^-""'^''^"^ 
'"'^-'"Hvl      made  H     inZth     V    ■!.      ■■     The  charge  of  incomplete- 

-  'i  -phrit.s  Xie ;   could  b^lf'^r!'""  "'"'"^  ^••"^•^•^-  Jt  '^"-^ 

"■"■"'••'•-'-"'US.,]'        uZ    i^«Sl  '"*°  "'■"*"  '"^''^titial.  acute 

'Im-  .        ■ "^^^.*"^^"*rhts<hsease;in  the  first,  exudnti'-e 

ti„   .         ,  prominent,  .n  the  last  M.ree.  degenerative      In 

;  are  m  the  kidney  itself,  while  in' t£last  ihr^e 
».Jj  degenerative,  due  to  toxemia,  although  n^t 


he  throm- 

■  I  inf.  <tion. 

'n  is  at  all  ad«fjuate, 

11  rapid  necrosis;  of 
ills  tie  infective,  abscess 
ingular  infarct  is  seen 
the  cortex  appears  as 
>f  the  largest  infarcts, 
»■  1'     earance  of  I.Io«kI 
'  ten!.     Hture;  an  infarct 
"ti  t   t'  surface  of  the 


''fer  unri 
th  th. 


Jiritis       *h  ;;■  ■       ^i^''*  hfading  the  lesions 
-  ner    i.e,  thai  degenerative  changes  are 
ar    ma.   h  dege.  .ratp     may  have  arisen  from  m. 


:i  of  the  4. 
■i  theunderst, 
'ver  l.issified' 


<)f  the  clinician  and  the 
f  any  disease;  it  seems  as 
i'intis,  just  as  the  clinicians 


.    1 


ill' 


61 0 


THE  IRISAHY  SYSTEM 


11 


Fi(i.  278 


Anemic  infani  ni  ciirlpi  nf  kiilnn  i,.  <,i  i     • 

side  and Tt  i;not  nn     'W   ;    "'  "'"'  "lV'''^t'"^''«J  ^"hanges  are  seen  si.l..  l.v 
oui  rne  other.     1  hero  are  two  extremes  between  which  lie  all  the  ,■■  ,.• 

first     ™°*"""'  """  "''■  ••"C.iti.llj  non-infctivc  will  !«,  deal,  „ith 


5ative  factor, 
lal  infection. 
i>f  a  kidney, 
pnchymatous 
^generate  by 
hritis  by  the 
cks  of  either 
>y  the  large, 
characters  of 
i,  one  might 


r 


of  cong'-^n-.n; 


one  or  tlie 
en  side  liy 
"xist  wiili- 
the  (■!.-<•<; 
■)ronii:  ^  lit 
of  parcn- 

lealt  with 


ACUTE  PARENCHYMATOUS  XEPIIRITIS  611 

i..  the  infectious  disease.     The  ,r!Jl.    ,,'•"'"*'''''• '''*'»'"' 
»ei,i„„.  i„  fact  it  is  Sate™!  ^SS  St^  e°„:^Ts:l„tt 


Fia.  279 


Fia.  280 


u.,h  J5  ,  "'■""'  P''«"«^''>™«tous  nephritis. 
»ith  marked  cloudy  .welling.  Cell  bodie,  an 
'loudy  »,th  beginning  diswoiution.  Note  varia- 
'"-n  m  nuclear  ,tain:  a.  pale  staining  nudei-  6 
■^"■Ply  staming,  c.  J,  interlubular  capillary;  ,  cell 
witli  pule  invisible  nucleus.  J'.'.ceii 


Acute  parenchymatous  nephriti.,  i  ,„.r 
stage  with  more  acute  disinlegraUon  ol  the 
cell  bodies  into  the  lumen. 


Kia.  281 


^"■it  lurcnohymatous  nephritis,  fully  develotx^       A  nK.,     .     ■    • 

-.-.ng  enlarged  stellate  Lint^,  ^"^^l^'^^Z^Z^;^  '""-■ 


.'  '  t.rin  parenchymatous  nephritis  be  iiseH      TK^  ^    x      . 
'^  •  ''^'t  i"  which  the  kidnev  tuhnles  an^  n^        IX  ^'''*  ?*'*^"«  ^""^^ 
."-tion  arresttHl  all  a  tnl  K  ^T-'f^l' *1*^'^  ""F'«  ^^H^^d 


'•    -  ""ution  arresttH^^  an  a  "n-^     "ecToscd.  tiieir  nuclei  killed, and 

"    'ii^  state,  therrmav  be  no  XL  ^'  ""  overwhelming  force  of  toxin; 

,  mere  may  be  no  changes  wrought  in  the  outward  shape  of 


012 


77/ A'  VlilXAIiY  SYSTEM 


wi.h  .he  dnrker-ml  mcliill,    n,.l    ™  f"™"-V  P«le  cortex  contras 

sra-  ;™i-  !;S  ^SP^^^. 

casts  appear  r-  he  ,„.r  *-' V"'^"'''-"-  «Pace,  and  bIcKxl  an.l  blocul 
nephritis!  Clear  sdV  1^1^  "  "^J^!  '^'  '^™  hemoixhagic 
toxen,ia,  nor  is  this  q  a  «H  bv    . .  I"":  ^f  t'^%"»t^«n>^  <'f  «  diffuse 

Chronic  Parenchymatous  Nephritis.- 'I'his  ff.rm    ..■M.A     i        u 
(liflnsc  nephritis    is  elnri,.f,.r:Lj  i         i  ,  •  ^   '''"*^"  ^^^^  chrome 

white,"  s,.L.tim;  -W  red  •  /•'  '.^*'"'  '^"''"•^■'  ^""'''ti'"-'^  "l«,fe 
bo  mereiv  „  cc"^in„ano  of  t'l,..  7"  !"««  mottled  kidney.-  It  max 
arise   in;i.lio„s  nV  u  ^  k-r  P7'-''y'""tcn,s  state,  or  it  m.; 

varietv  of  <.han.e  'H  e  ,1  -.Ho  V  /.'^  the  alcohohe  exhibits  this 
tant  faetor  i  1 1  e  in  t;.  |  '  of"  .  '  ''""'^-'/"I'ules  is  an  impor- 
•listinKuish  her  n  "  rt .'  ,.  T  •  'I'^V''  '"  "^'''^i""  «hilo  w-' 
notable  t  at  t  is  „ii  ,/'''?''""  ;"*  ^''^  ^nt.rM[t\^  tissue,  it  i> 
tissue,  and  as  fibroSas  •  .,  '      ""  "^  ^P'•'»^'■^*•^ation  of  eonneetix. 

of  itsinereai.rsS       H  i^"nZs;:r  7  ''I""  ''"-  '""-^'^  *''^  --" 
finally  hy  eontraetion  if  t le   .•        .1     '*,  enlargement,  to  be  followe.i 

tissue  of  the  k  ,    e     '  l-.v     '      T       T  '""^  ^■"""«''-     '^''^^  conneetix. 

area  in  \^ZnZl^^Z^^i'7"    "'  ^•""^'-t  ^"^  ti««"e  of  any  otlur 

crease.l,  and  Z^Z^l    ^,  Y     '        M"^"'  V'  ^^•''"•''  '*«  ^-Ik  is  i„- 
.sin)s(c,iunti,  to  a  sta^c  m  whieh  its  bulk  is  lessenetl  by  tl„ 

in  a^pcrs.:":!;;;,,;:;;'';:;;:,:;:!;! .^^i^koM  sug«est«  that  the  w  n,ottied  ki,.,,,.. 

^iimli  i-.«b.,li  ,„  the  glomeruli  and  eSprn"l'wif''''^^.™''''?"^'''«' '»''''  «>"'":''• 
cireuliUiou.  *        '^"'-  "*'"'  elsewhere  with  resulting  local  disturbanc-  ni 


Fio.  282 


<«>ntraction  of  fibrosis     Itfl.i.«««»,  *• 

:'^'>u«  nephritis  is  but  a.   oaXr  s    ™T.rth""*''•'^^^''';"T■^'^«^ 
iMtcrstitial  nephritis.  *^'  "'^  *''''  so-called  .lifFuse  chronic 

The  enlargement  of  the  ki.lnev  si\es 
'   "  Pli'rap  look  and  if  it  be  held  with 
"-  PHvis  .n  th..  pahn  of  the  I  a  d     t 
-•nvex  surface  looks  broad,  somewh  t 
^'1  "are,  and  there  mav  even  b,'    .  L" 

;'',.«;'tt-ingaIon,  ti.e"co;.    :xbod: 
"''-'••'   reminds  one  of  the  h,,mtu  Inl 

;.rrowoverthespineofafath.,,!:;w 
'';•■  "ame  "hog-back"  ki.lnev .  'Hi,      "  ! 

"'-^nuadnWateral  shape  mav J  ;;"";■ 
'"'   'y/'S^-'Htal.     The    bulkv    kidnev    ,s 
-"u-nmes   soft,   although  if  co  "^i^t. 
t's  firm,  the  c;apsule  peels  rea,lilv  ^ 
'••='; t's  a  smooth  surface  on  whic"h 

v'".s  are  .lilated  an.1  prominent     Tit 

;;;;;;■•;;"« -lor  m 

■'l'1-arance  .s  due  to  the   prten!;    l.'t 


1"^,      '""""■'"■'' "Pilhelium  lining  the 
'■•^■.■onv,>luu.d„.bu,e.,.     Asi„,,i™ted 

.ml™     ""'"'"   ""■   '""•""matory 
l'n,.oss  .8  Lore  ,till  .ominuing. 


'•'  I'lvhitf  r„)  a 


ami  „„al|  granular.  c.,ntn.,.,e.lki.ln..y, 


8  ('.)  (one-half  natural  ,i,e).  to, ho 


w  rHative  siip. 


■ ' '  -e  or  *„„,  ,„,i„„  wS''t;,'T:;,r*,,X"'r: 


614 


TJIR  VRISARY  SYflTEM 


B  ! 


that  a  gl«rnerJh>?„    V  i  „,  to  b/^'i;;  '  t  '^'•^^•/•''^'"  '"''"'^*^'^- 

c  isconnble,  may  be  a  definite,  eas 
(listinj;ui.s|,e(J  line  „f  perceptible  thic 
ness  tile  first  indication  of  interstiti 
proliferation. 

Chronic  Interstitial   Nephritip  —  Tl 
above  form    may    ,,roKres,s    into  tlii 
or  the  interstitiai   form  may,    on  tl 
otluT  hand.  Kra.iually  arise  in  a  kidne 
t  lat  at  no  time  has  been  much  larg. 
than  usual.     Considering  that  there  ai 
yanous  Kra.  es  of  invoK  ement,  a  kidne 
ypic-al  of  the  a.hanml  condition  wi 
be  .lescnbe.1.     For  such  there  are  man 
names    such  a.s  granular  ki.lnev,  con 
tr-  ed    kidney,    small    white    kidnev 
fi'To.d     nrrhotic   or   .sclerotic    kidnev 
or  the  kidney  of  indurative  nephritis 
i  iHTc  seen,  to  be  many  different  wav. 
at  least   by  whicli  a  kidney  arrives  af 
tins;   as    a   .swjuel  to   parenchvmatou.^ 
iicpliritis    as  a  sequel  to  acute  nephritis 
without  the  interposition  of  a  stage  in 
which  the  kidney  is  large,  from  arterio- 
poisons  like  lead,  and  •,.  .,  r.!'nu7''\  ,  ^""*'    ^'^"""^    chemical 

hard,  firmly  elasti  •  !  i  ^  ihe  kil  "  V '^"  ^^'  '^'^"^>'  '''  «'»""' 
small  knobs  of  a  few  m  linl  l  ■  'i  '  "'  ""^^  '"'"^"^^  '^  '•o"k!'  «"'' 
rcmo^■e  the  caj.sul  V"  "  "f ^  •'""''''■•  V'^^*^"  ""«  ««empts  to 
of  much  pulling  and  Ih  i?  !  ?'■  '"  '"•"'^'  P'*"^^^  ^^'"^^  the  exercis,- 
hreaking  tl.,.  itv  fib  o^V',  I.  ,  >^'"'K -^I^PPed  one  may  see  gradually 

itself  niay  be n,,,chth  Sir  ctso;  •'"'  *'^'1  '*•  ^^^'  ^^P^'' 
to  be  seen  bv  the  naked  e;  .^'t     *^ ''«"«"«  «'^»'.  ^roni  those scaraiy 

jut  from  thesurface  or  be  ml  I^^V  centimeter  in  diameter,  m..^ 
them.  The  peK^  Ionics  iT  I  *  "'  ''"*'  ^  '*'*^«^  fl"'^  runs  out  -if 
lying  in  tl...  CO  .,;  J  -e  ^iir?  T"^  "'■''""'  '?  "■'*"'^"^^-  ^-^n^Werable  .at 
that  the  kidne",  secti-r  ''"'"  '\''"'^  ^^'  kWney  sub.stane.    . 

"H..  on  .section  may  prove  to  be  yet  smaller  than  it  seen.,  d. 


CUn.uiv  in.e,Mi,i„|  m.„l,ri,i.s  u„,,,i|  «r-,„. 
ular  k.dn,-, ,.     (MKii.i  P,„i,    Mus.) 


ina,  the  most 
suggest  that 
>ts.     Fats  or 
■h  tend  often 
>■  be  seen  in 
stitial  tissue, 
isule,  or  the 
lobulattd,  so 
more  lobes, 
ace,  and  the 
ind  scarcely 
Snite,  easily 
'tible  thick- 
interstitial 

itip.  —  The 

into  this: 
ly,    on  the 
n  a  kidney 
luch  larger 
it  there  arc 
it,  a  kidney 
dition  wiil 
•  are  many 
Iney,  con- 
e   kidney, 
c    kidney, 

nephritis, 
rent  ways 
arrives  at 
hymatous 

nephritis 
I  stage  ill 
n  arteriti 

chemical 

is  small, 
>ugli  with 
empts  til 
!  exercisi 
?raduall\ 
!  capsuli' 
!  scarcriy 
ter,  niii,\ 
IS  out  ol' 
•able  tut 
tanci'.   ;> 
seenii  il. 


CIIROXW  IKTERSTITIAL  XKHlRITIS  ni 5 

...;sv  exhibit  a„,v  wiilr  *,  t%i«^;  '"rS''' ;■"'•  r*''-  ^ 


-''!•!•"  more  S^'m,2irffrh'V""""''''»'''''»"«««Pt^ 
;-   l«rRo,aml  the  ™XE,Jt «"'',';''»  T  °'l'"  '"«'•  """■"toes 


(>U\ 


THE  rmxAHY  system 


merely  by  a  round  hyaline  mass  in  which  a  few  flattened  nuclei  are 
seen;  tiiese  are  evidently  (jnite  out  of  commission.  On  coordinating 
the  Kross  and  microscopic  a|)i)carance,  it  is  found  that  the  granular 
surface  is  due  to  the  effect  of  fibrosis;  where  a  bami  of  fibrous  tissue  has 
pulled  it)  the  capsule,  a  depression  exists  on  the  surface,  and  the  knobs 
are  the  i)rojection  of  masses  of  tissue  not  |)ulled  in  by  the  fibrosis  (see 
Fig.  L'N.'>).  If  such  a  kidney  have  suflicio  "  tubules  left,  it  may  show  the 
marks  of  cloudy  swelling,  but  too  often  there  are  no^  enough  for  this, 
and  the  cut  etige  remains  flat  and  well-definwl,  without  any  eversion 
of  the  edge.  One  is  struck  by  the  large  amount  of  urine  that  can  l)e 
secreted  by  such  a  damaged  kidney. 


Fl(l.   286 


Ficj,  287 


.^  V>"  ■^^ifgr.;%L 


Surface  of  an  arterinsclerotic  kidney  to  show 
the  charartcristif  depressioni*  («), 


Seoliiin  from  a  raac  of  acute  scarlatinal  nephri- 
tis: convoluted  tubules  showing  acute  parenchym- 
atous together  with  acute  interstitial  nephritis,  evi- 
<lcnce<l  l)y  the  plasma  cell  infiltration:  a,  a,  between 
the  tubules 


Acute  Interstitial  Nephritis.-  In  this  and  the  related  infective,  .septic, 
and  suppurative  conditions  we  have  to  consider  a  twofold  circumstance: 
(1)  that  there  are  more  or  less  marked,  the  results  of  the  toxins  act- 
ing in  some  of  the  ways  \,o  have  just  considered,  and  (2)  that  there 
is  active  inflammation  following  infection  of  the  kidney  tissue  itself. 
Before  i)rocee<ling  to  the  infective  states  proper  of  the  kidney,  the  reader 
may  be  reniinded  that  in  cases  of  infectious  disease  such  as  scarlet  fever, 
there  is  an  interstitial  exudation  of  marked  degree,  but  we  would  ratlicr 
consider  this  as  a  fortuitous  mtnlification  of  a  (primarily)  parenchym- 
atous nephritis  than  give  the  impression  that  Bright's  disease  has  an 
acute  interstitial  type  peculiar  to  it. 

Infection  reaches  the  kidney  through  the  blood,  or  from  the  un  tcr 
and  pelvis  up  tlu"  tubules,  or  more  rarely  directly  from  without,  as  from 
a  wound,  or  equally  rarely  by  extension  from  a  nearby  structure. 

In  a  stage  earlier  than  that  of  suppuration,  a  kidney  so  infected  will 


ACr'TK  tXTERSTfTfAL  SEPIIRITIS  017 

show  cellular  infiltration  of  the  type  familiar  in  acute  inflammation. 
..nd  an  accompanymg  cloudy  swelling  of  the  tubules.     Such  constil 

iites  the  not-often-.^en  typical  picture  of  acute  interstitial  lu  i.hritis. 
It  IS  m  the  more  advance<l  forms  that  we  shall  consider  it  as  these 
are  so  much  more  important  practically. 

The  source  of  the  infecti.)n,  whether  from  the  bl.md  (,r  by  way  of  the 

nbules  makes  some  difference  in  the  .listribution  of  the  abscesses.  In 
the  former  case  the  kidney  is  infected,  like  other  organs,  bv  the  bacteria 
in  the  blood;  actual  embo  i  may  be  the  form  in  which  they  are  carrS 

h  s  IS  especia  ly  noticeable  in  cases  of  subacute  vegetative  endocanlitis. 
...d  here  actual  small  mtarcts  or  areas  of  necrosis  involve  i.ortions  of  the 
.lomeruh.  Both  kidneys  are  involved,  and  the  sites  of  infection  a  e 
scattered  apparently  at  random;  if  suppuration  has  not  occurred,  hvper- 
.nuc  areas  with  mottling  may  indicate  the  sp<.ts  where  the  inflammation 
IS  progressive;  if  suppuration  has  occurre<l.  the  cut  surface  shows  small 
...nltiple  abscesses,  which  may  appear  on  the  surface  also;  when  the  cap- 

i    i^romir  T^■Y^  """^  -^''"^  "•'"  "««"'^t  the  re<l,len«l 

1  Kkground.  Ihe  abscesses  in  the  ,,apillary  part  of  the  kidiiev  mav  be 
.ungated  indicating  that  m  this  ,lirec-tion  the  pus  foun.l  least  r^sistanc^ 
.isnyhere  they  are  usually  round.  In  an  a.scending  infection  from  th; 
I..IV.S.  the  abscesses  tend  to  be  linear,  or  to  be  arranged  in  groups  thai 
arc  linear,  following  the  course  of  radii  from  the  tip  of  a  pvrami,  to  the 
.  ..rtcx;  in  a  section  of  the  whole  kidney,  abscesses  may  be'^'st^n  a  rangS 
along  such  radii,  but  not  continuously  so.  parts  of  the  tubule  that  ha^e 
>orv.;d  for  the  coiuluctum  of  the  infection  being  spared.  Micro^ 
M.-pically.  the  abscess  presents  nothing  that  necl  be  here  detailed- 
tl...  surrounding  tissue  may  show  ce<lema.  and  .legrees  of  infiltratbn 

"Ski  rtrif  ?J''  ''-r?  '^""!  *''^'  ^^^^^'^  *»-  parencVma 

..  n   1  •  ^.f'^*r^  «^  !""^'>  '^fo™  the  general  s>  stemic  toxemi^  as 

tn.n,  the  proximity  of  the  abscess;  by  this  is  meant  that  if  a  tubule  near 

an  abscess  be  m  a  state  of  cloudy  swelling  it  may  have  been  rencS 

■n  I  r  "'"'/'i!'*  '•'"',  ^•'."»^o"gi"ally  from  this  or  another  absct'ss 
and  traversed  the  circulation  before  reaching  the  tubule 

Nuh  a  condition  of  the  ki.lney  tissue  is  usually  called  suppurative 

.hntis.  in  older  phraseology  "surgical  kidney";  in  the  case  in  which 
I  i>  «ause<i  by  an  ascending  infection  the  pelvis  must  have  been  first 
;';■;•;•.  (Pyehtis),  so  that  as  soon  as  the  kidney  has  become  involvS 
n,a  speak  „t  u  pyelonephritis;  should  the  abscesses  become  large,  so 
"  .  t  the  kidney  is  converted  into  a  sac  full  of  pus.  the  condition  is 
;   i  "<!  pyonephrosis.     .Should  the  abscesses  remain  small  and  e  ic^su! 

'.  healing  may  ensue.  On  the  other  hand,  the  infection  mav  sp  ead 
e  .ssues  around  the  kuliun-  with  the  ultimate  formation  of  abscess 
'      I.  ;se  (..nnective  tissues,  the  so-called  perinephric  abscess. 

I. .ore  leaving  the  suppurative  processes  of  the  kidney,  it  mav  be  said 

;ep,.o,en,c 

".I'sposing  cause;  the  sac  in  which  the  stone  lie,  mav  remlily  become 


■.JM 


MS 


TIIK  IIUXAKY  SYSTEM 


infecte.1.  and  a  calculous  pyonephrosis  bt-  the  result.  On  opening  such 
a  kidney,  the  sae  wall  is  apt  to  hi-  fairly  thiek.  made  of  the  compressed 
kidney  tissue  fortified  l,y  the  capsule;  the  inner  wall  is  often  smooth 
and  tJie  calculus  may  l)e  seen  adapted  in  shape  to  the  In-d  in  which  it 
lies;  the  pus  may  have  no  outlet,  and  in  process  of  time  mav  bt'come 
mspissated  or  even  calcified. 

In  the  above  paragraphs  it  may  seem  that  the  classification  of  neph- 
ritis has  been  reducwl  tt)  terms  too  simple  to  Iw  effective;  it  may  be 
pointed  out    however,  that  the  great  complexity  of  terms  generallv 
m  use  would  never  have  arisen  if  there  had  been  a  well-understood 
relationship  between  clinical  signs  and  pathological  observations.    The 
truth  IS  that  no  such  accurate  correlation  exists;  the  clinical  observa- 
tions are  very  often  merely  variations  upon  the  old  theme  of  albumin, 
oasts,  and  oedema,  while  the  pathoh)gical  observations  are  bewilder- 
ngly  diverse.     In  the  present  state  of  our  knowledge  it  is  not  often 
safe  to  preilict  what  kind  of  kidney  is  going  to  be  found  in  any  given 
case;  anyone  who  has  followed  his  cases  to  the  autopsv  table  has  found 
small  granular  kidne\s  where  he  expected  large  wliite  kidnevs,  and 
normal  looking  kidneys  where  he  expected  small  granular  kidnevs 
and  so  on;  little  or  no  dependence  is  to  be  put  upon  the  value  of  granular 
or  hyaline  casts  as  indicating  ditterences  of  lesion;  the  urine  examined 
IS  an  infinitesimal  fraction  of  that  excrete.1;  the  amount  of  urine  and 
the  number  of  casts  must  vary  according  to  the  amount  of  the  urine 
and  the  completeness  of  the  centrifugalization;  and  the  reparative 
process  in  the  kidnej-  may  exceed  our  expectation.     We  have  some 
admiration  for  a  certain  pathologist  of  eminence  whose  pathological 
diagnosis  rests  content  with  the  simple  statement  that  "the  kidnevs 
indicate  Brighfs  disease,"  without  attempting  any  more  elaborate 
refinement. 

Tuberculosis.— Tuberculosis  of  the  kidney  may  be  part  of  a  general 
infection  or  part,  even  the  chief  lesion,  of  an  infection  confined  largelv, 
if  not  entirely,  to  the  genito-urinary  system.  It  is  theoretically  possible 
that  tuberculosis  might  be  primary  in  the  kidney,  the  bacilli  having 
gained  no  foothold  and  having  caused  no  permanent  lesion  at  their 
place  of  entry.  It  is  not  likely,  however,  that  sutL  conditions  oh.  in 
frequently;  careful  examination  will  usually  reveal  a  latent  or  quietly 
active  focus  in  some  lymph  node  or  elsewhere. 

As  part  of  a  general  miliary  tuberculosis,  the  lesions  in  the  kidnev 
are  seen  as  small  hyperemic  spots  that  on  section  are  leukocytic  or 
lymphocytic  collections,  or  as  larger  greyish  or  white  dots  appearing 
through  the  substance  and  on  the  surface  ol  the  organ;  eariy  abscesses 
or  small  fibromas  may  be  mistaken  bj-  the  naked  eve  for  tubercles. 
Ihese  last  seem  to  arise  oftener  in  connection  with  "the  intertubuhir 
than  with  the  glomer'Ui. 

In  localized  tuberculosis  of  the  genito-urinary  tract,  the  involvi- 
ment  of  the  kidney  is  more  extensive,  the  infection  is  often  bilater!'! 
usually  unequally  advanced  on  the  two  sides,  and  caseation  readih 


TVBEItCULnsiS  OF  THE  KIDSKY 


019 


Kip    288 


mrurs;  the  pelvis    if  not  primarily  affecteti,  quicklv   becomes    so. 
\\liether,  m  fact,  the  infection   travels   from   bhuMer  to  iiidnev  or 
tn.in  kidney  t<.  Ijlaclder  is  a  <iebated  point;  a  good  manv  cases  ^m 
to  he  definitely  the  latter.    The  caseated  masses  mav  fuse  until  the 
(iitire  kidney  seems  to  be  a  series  of  compartments  full  of  caseous 
or  casei^purulent  matter;  between  them  septa  run;  half  a  dozen  of 
such  sacs  may  seem  to  fill  the  entire  organ,  including  the  pelvis,  and  the 
(•apsule,  aid«l  or  not  by  a  thin  compressed  layer  of  kidiiev  tissue,  may 
!..■  the  external  covering  (tubereolous  pyonephroBia).     Except  in  the 
(iisf  of  the  ureter  becoming  blocked  or  its  walls  gummed  together. 
pus  and  at  times  bloo<l  will  escape 
into  the  urine,  and  tubercle  bacilli 
may  l)e  detected.     This  is,  of  course. 
jHissible  only  when  the  lesion  becomes 
ail  "open"  one,  because  in  the  case 
of  thoroughly-  circumscribetl  caseous 
areas  or  of  miliary  tubercles,  no  Wi.y 
of  escape  is  present.     Much  care  has 
heeii  taken  with  the  detail  necessary 
to  determine  tubercle  bacilli  in   the 
urine;  it  is  necessary  to  be  sure  that 
w  liat  seem  to  be  tubercle  bacilli  are 
iii't   in  reality  smegma  bacilli,  which 
are  acid-fast.     The  formamin  method 
has  simplified  the  search  a  good  deal. 
It  seems  to  be  now   generally   con- 
eeded    that   no   differential  stain    is 
infallible;  the  greatest  care  must  be 
taken  to  wash  the  external  orifices, 
to  obtain  the  urine  by  catheter,  and 
hiiaily  to  use  absolute  alcohol  as  a 
tlecolorizer  in   addition  to  the  ordi- 
narily employed  dilute  mineral  acid. 

Syphilis. — Apart  from  the  rare  oc- 
I  iirrence  of  gumma   in    tht   kidney, 

tile  recognition  of  syphilis  in  the  kidney  by  anv  naked-eve  lesion  is 
;i  ni).+*or  of  great  uncertainty.  The  kidney  of  the  newborn  is  some- 
'imi  und  affected,  and  the  Treponema  palliduvi  has  been  demon- 
iriitc  Even  the  picture  of  multiple  scarring  which  is  attributed  to 
^  I'iiih-    may  be  copied  by  lesions  of  a  less  specific  nature. 

Actinomycosis,  glanders,  and  leprosy  have  been  known  to  affect  the 

"lev,  but  all  are  rare. 

Regressive  Tissue  Changes.- Atrophy.— Apart  from  the  atrophy  of 

rosis  which  IS  a  familiar  picture,  atrophy  may  be  said  to  occur  in 

r;isimis  and  in  senility,  but  it  must  be  remembered  that  in  the  latter 
n  tiie  arterial  changes  of  old  age  may  be  the  cause.     Atrophy  from 

'  ti\  ity  occurs  in  tubules  whose  glomeruli  are  damaged  or  congenitally 


TulK.rculo8i«  of  kidney;  one-half  of  the 
.>rgHn  from  a  cage  of  tuberculous  pyonephro- 
sis: the  organ  ia  converted  into  a  series  of 
xica  filled  with  brittle  caseous  matter. 
(MeGill  Path.  Mus.) 


k:.| 


(;2() 


THE  rmsWHY  SYSTEM 


i 

Ifj 

1 


imperfect.     Pressure  atropl.y  (Mcurs  i„  hy<lr(.nepl.r.)sis,  In'rause  th, 
o|^striKti..n   t..  the  c.tfl.m- of  urine   renders  the   intraren.-.l   pressur. 

aoudy  Swellinr  It  will  l,e  alrea.ly  Hear  that  this  results  fr..n,  t«,xi„. 
o  n,„ny  kuuls.  1  he  <e  Is  ar;-  enlarge.!.  .,f  Kn.un.l-Klass  appearance 
ami  he  lurm-n  .s  re<lu<r,l  n.  s>ze.  The  Lest  n.eth.Ml  .,f  .le.nonstratint 
clou.ly  swellu.K  <s  to  exanutu-  l.y  the  microscope  a  section  cut  bv  freez- 
ing,  without  prelinunary  treatment  of  any  kin.l;  the  healihv  tubule^ 
api)ear  colorless,  the  tubules  that  are  swollen  are  grvv  an.i  opaque 
acetic  aci.l  clears  them.  In  the  staine<l  section  the  lumen  of  the  tubule 
may  be  stellate,  an.l  the  staining  |)ower  of  the  nucleus  less  than  usual 
,  Fatty  Degeneration.  This,  like  the  previous  .hauKe.  which  it  follows 
IS  seen  to  best  m hantuKc  in  the  com ..lutcnl  tubules.  Fat  droplets  mav 
be  <lemonstrat«l  by  the  use  of  Sudan  III.  the  jcranules  or  droplets 
api)earing  golden  or  yellow.  ' 

Hyaline  Degeneration.-This  is  to  be  .seen  in  any  section  of  aclvanctnl 

interstitial  nephritis,  the  gh.nieruli  a,>pearinK  as  n.uiid  masses,  smaller 

han  normal      J  he  hyaline  cast  is  probal,ly  ,lue  to  the  c-hange  undergone 

b>  epithelial  c-ells  after  they  are  shtnl,  although  occasionally  coagulated 

albumin  may  form  a  cast  of  like  appearance. 

Vacuole  Degeneration  Vacuoles  may  be  seen  in  the  epithelium  of 
severely  damage,  tubules  in  nephritis,  usually  occupving  the  part  of 
the  cell  nearest  the  lumen;  the  discharge  of  such  vacuoles  is  thought 
to  increase  the  all)uinui  in  the  urine. 

,  Amyldd.-This  apjH'ars  in  the  ki.lney  us  a  deposit  occurring  first 
in  the  glomeruli  in  cases  of  general  amyloid  de,«,sit.  The  condition 
has  no  hing  to  do  with  the  appearance  of  the  waxy,  .so-called  amvloi.l 
cast,  which  IS  probably  a  m.Hlification  of  the  more  frequently  seen  hvaline 
cast  In  advanced  cases  not  only  the  glomeruli  are  amvloid.  but  the 
capillaries  and  the  l.a.semcnt  membranes  of  the  tubules  show  the  change. 
Ihe  ^-essel  walls  are  thickened,  transparent,  and  the  lumina  mav  be 
almost  <,r  entirely  obliterated.  In  an  advanced  case,  the  cortex  is 
greyish,  in  plact-s  translucent,  and  the  glomeruli  mav  be  recognizable 
as  grey  dots,  which  react  to  the  tests  referred  to  in  the  paragraphs 
dealing  with  amyhud  in  general. 

Pigments  -Pigments  found  in  the  kidney  are  derived  from  the  blood 
or  bile.     IJIood  pigments  may  be  laid  down  in  any  part  of  the  kidnev 
appearing  even  in  the  .secreting  cells.     Bile  pigments  lead  to  a  ditfuH. 
or  circumscribed  greenish  or  yellow  color,   the  secreting  cells  again 
readily  becoming  af'ected. 

Uric  Acid.— Ileferencc  has  been  made  elsewhere  (p.  317)  to  the  ill- 
understood  deposit  of  urates  s. m  in  the  tips  of  the  pyramids  in  infants 
at  birth  or  shortly  alter,  the  .s,,lts  are  de|)osited  in  the  lumina  of  the 
discharging  tubules. 

Progressive  Tissue  Changes.-Hypertrophy  When  one  kidncN  i^ 
removed  the  remaimng  .mc  gmws  larger  by  :uercasc  in  the  sizl-  „f 
the  glomeruli  and  th.   tubules;  it  is  not  certain  that  in  the  very  your- 


77/ A-  KH).\fCr~ri  MORS 


621 


Iht..  is  not  an  actual  growth  of  new  tul.ul.s.  |,„t  s..«l,  is  unlikclv. 

I  Ik- vounKt-r  the  ,M-rson.  tlu-  Kmtt.T  is  the  .•apacity  for  l.vrMTtrophv." 

Tumors.-     t  will  hv  nrall,.!  tli.-.t  ti.e  mixnl  t.in.ors  of  the  ki.lnev  arc 
nt  .•onsi.lerahl.-  important.'  an<l  .•mhry„loKi,al  int.Ttst   (m-,-  p.  210) 
Apart  from  toratol,  astonms,  then-  an-  c-rtain  nu-sohlastic  tumors  to  Ik^ 
« onsulerwl  of  l..,th  hylic  am!  h'pidic  t\  pes. 

,.|-  wh?fT*  l''''"''V-T  """"  «''"'"'^""'«««-^.  appi-aring  i„  th.-  ki.lnev, 
u  whitish  ,.oor.  which  an.  apt  t..  U"  mistaken  for  miliary  t.ilHTcles 
or  ,.Nc„  for  al,sccsses.  They  are  usually  so  small  as  to  he'barelv  ,lis- 
ti..«uish,Hl  by  the  eye.  <,r  may  reach  the  size  of  a  pi.ihea.l 

LipomM,  myomas,  and  myzoinu  arc  occasioii,,l|\-  seen.     The  niire 

poina  IS  usually  small  hut  large  ones  have  hccn  reportcl.  an.l  Ihev 
..n>  to  he  (listinKUishe,l  from  the  "hypernephromas."  which  also  mav  he 
very  rich  in  fat.  Most  s,Hcall«l  myxomas  are  .as.,  of  mvx.>matous 
.l.«.nerati..n  of  some  ..ther  f..rm  of  tum..r.  'I'he  so^-alletl  Mriom*  is 
pn.lmhly  always  more  correctiv  a  telanfiectasis 

Adenomas.-  These  vary  in  size  fr.)m  a  millimeter  in  diameter  t.. 
>.v.ra  centimeters,  are  single  ..r  multiple,  soft  and  white.  Hist.n 
"l^ncally.  they  are  s..l..    or  tubular,  ma.ie  of  c.lumnar  «.lls.  an.l  the 

1.I..S  may  even  be  .lilate.1  into  cysts.  These  aden.,mas  arJ  prone  in 
I.  .■  life  to  give  rise  t..  carcm..ma.  an.l  b.,th  terms,  considering  th.- 
on«>n  of  the  ki.lney.  have  t..  be  ilschI  in  their  hist.,I.,gi,.al  sense 

■  m      tluTwisc;  th.-  .  lagimsis  iK-tween  a.len.mm  and  the  malignant 
^muth  may  be  .lifhcult  to  make.  esiK-cially  in  those  carcinomas  arising 
n.n,  the  tubular  ep.thel  um,  as  .listinct  from  th.,se  of  pelvie  origin 
.  M.,rrh..us.  simpe.  an.l  mclullary  types  are  f.,un.l.  th.' tum..r  bdng 

N  ..  ,„.,s.     I  rone  to  degeneration,  hemorrhage  is  a  likelv  .)ceur;ence 

.  Huiulary  carcinomas  are  more  common  in  th.-  kidnev  than  primarv 

Sarcomas.-Kndothelio.nas,   peritheliomas,   an.l   sarcomas  <  f  ,i 

;l  s  .in.  le  eel  s  are  foun.l  in  the  ki.lney.  b..th  in  youth  ..nd  in  add 

•  .  the  large  tumors    supposedly  of  this  nature,  in  th.    ^er^   voung 

"itn.  pn.ve  t..  be  mixed  (teratoid)  tumors  rather  than  pur,  sircomas 

.l.™f^Tr  ^-»f  ^"r f-^-'^'^r  ^'^  ^--'  «'  birth  or  sT-rtlv 

'         h-generat,on,  and  have  l^n  known  by  a  great  variety  of  name 

:  "l"<li  the  sarc..matous  nature  is  recognize.1.     The  growth  consists 

<  sarc-oma-like  matrix  in  which  there  are  epithelial  elements   somt 

-  tubular,  as  well  as  fat,  muscle,  cartilage,  and  s.,  on.     Thev  som^ 

tn,M ,  jrrovv  to  a  size  truly  enormous.  • 

Hypemephromas."--These,  which  we  have  el.sewhere  referre.1  to  as 
..chomas(seep.27.^;,are  masses  .,fc.,n^^ 

-a  connective-tissue  capsuh.,  fr.,m  which  septa  run  into  the  ma.s 
-  tnm.jr^    1  he  tumor  is  usually  soft,  yellowish,  or  brown,  often  red 
'        H^norrhage  an.l  in  some  cases  large  collections  of  clot  ;?e  found 
1       ieu  growth  pushes  the  kidney  tissue  before  it,  so  that  this  mav  1  e 


622 


rilK  (  inWMiY  SYSTEM 


sima.l  nut  upon  tiit-  siirfiut-  ..f  tlir  tum..r.  Metastases  readiJv  oc 
IIistoloKHally.  the  tumor  (•oii>i-is  of  ;i  nu-sliwork  of  capillaries,  \ 
rows  of  (rlls  variously  arratiKitl  aioiig  tlu-m;  ti,e  ci'lls  are  often 
those  of  the  adrenal  cortex,  wliile  in  pla-^-:  they  are  ..•  anKwl 
masses  au<l  look  like  eti-lothelial  .•-lis,  whi.h  latter  are  in  tact  sonietj, 
pruliferated.  'lluis,  .1  hyix-rnepuroma  at  one  place  niav  l(K)k  like 
anponia,  at  another  1  ke  an  endothelioma,  or  even  like  a  sarcoma 


1 1.1  im 


iMi 


Fio.  290 


SwtioD  of  a  portion  of  a  hypcrucphronui  pf 
the  kidney.  A  iharaclerintii-  area  ahuwinit 
column*  of  clear  polygonal  r<ll»,  a,  lying  in 
imnie<liate  apposition  to  ihi  eiiilolh<'liiim  (./) 
of  the  capillary  ninusrs  (cl.  At  ft,  arena  <jf 
infiltration  anfj  ilrgenerttion. 


Section  from  another  portion  o(  th«  aa 
tumor,  more  highly  magnified,  »hoK 
tuliiilar  arrangcii.cut:  o,  awollen  traB»luc 
tumor  cellK  surrounding  a  definite  iuni 
A.  capillary:  <,  fat  droplet*  in  tumor  <x 
(Buday.) 


carcmoma.    The  cells  are  usually  ix.lygonal,  but  may  be  cubical  ^ 
columnar.     An  abundance  of  fat  i;,  sometimes  seen  in  the  cells. 

Cyste.— Reference  has  already  been  made  to  congenital  cystic  kidiie; 
retention  cysts  are  very  common,  either  as  the  comparatively  snia 
ones  to  be  found  in  the  kiflney  of  ititerstitial  nephritis  or  the  larger  oik 
that  ap{>ear  in  otherwise  fairly  healthy  kidnevs  of  old  people. 


!in 


THE  URETERS 

Abnormalities. —The  congenital  anomalies  of  the  ureters  mi 
neces.sariiy  of  the  ki.lney  pelves)  have  been  considered  with  those  c 
the  kidney;  the  circulatory  disturbances  are  of  no  moment,  apart  iroii 
their  occurrence  as  features  of  more  serious  changes.     Foreign  hody 


77/ A-   IRKT/tUs 


623 


«  -state  of  affairs  that  s.H,n  allows  the  suppur..   .   .rspreac   to  th^ 

n<..  to  r.n«I       I-  ^'''^  "'"^*"  ^"^^"^  t'l^  bladder.     This  gives 

riM-  to  renal  colic  or  more  str  ctiv  nrataral  .•aH^    „   .  •        ^ 

">nii.hcation  of  nephrollthimid.fl       ^  I'  ^-  '"'^'  "»l>«rt«nt 

»s  a  foreien  bodv  in  t),.>  ..,  ♦    '    nn.  '    "^  "'^  *  *"'""'"  ™ay  act 

■".)■  =r,«  from  the  internal    ,„se,  tlS  to  aCe   .;.  ^^^^'T 
Impure  fmm  outside   »hich  „  ,v  be  exeS  by  .  .ariet  .    ■     i      ^^ 

-"'^'We  to  eianl    anfr  h    ^"'*^-  ^^'^   """^  '^•**^  i"*"  it  i. 

" V  ^^rb  l:'i£:„^7rrLw^it'r'if-'S''  ■"^■"■^ 

spn  mliiii;  bv  contiViii-fv.  «-Tk    •  *     •         ("**•"*").  the  inflammatbn 

t  ■'';^|<^f^"^sSS":™i;eS,'°sS 

.  »el,t«  and  uretenfs  occur  bj-  extension  of  a  ber,oge„o;;^ 


(»24 


TIIK  llilSMiY  SYSTEM 


infection  .,f  the  ki.lney.     The  ,,y.,Kenie  ccc-i.  Baciili.s  coll.  a.ul  «,„,,. 
infeet  the  ether  by  way  of  the  ureters  and  hhi.lder 

nv  V  '  .  the  h„,„K  membrane  „f  the  pelvis,  or  the  fluid  exuded 

max  be  purulent,  with  or  without  the  formation  of  a  membrane;  ..hen 
stone  IS  present,  the  irritant  effect  of  the  stone  superad.led  mav  result 
m  an  ulcerative  or  even  a  Ranffrenous  state  of  the  wall.  When  the 
.nflamma  ion  is  of  long  duration.  pro<luctive  iaflammatorv  overcrow  hs 
<>  papillate  nature  may  be  noticed.  The  ureter  in  its  course  caS  rJpro^ 
luce  any  or  all  of  these  states,  although  the  complications  due  to  tll^ 
presence  of  a  stone  are  infrequent,  because  the  stone  is  not  likelv  to 

tZ""  Fi nl'll- ■  T-  T*;'"'*'""*.  Pr"'P'*"^'"«  *'•*'  ^.vmptoms  of  obstruc- 
tion I-i,  alh,  It  IS  to  l>e  noted  that  in  states  of  chronic  inflammation 
the  pelvis  and  ureter  formed  masses  of  mucin  may  be  thrown  off 
\n  the  surfat-es,  and  their  passage  down  to  the  bladder  mav  be  the 
t)ccasion  of  attacks  of  ureteral  colic.  ^ 

Tuberculosis.- Miliary  tubercles  may  Ik-  found  in  the  pehis  or  ureter 
ta  of  IfnT-  "^  tuberculosis,  but  more  often  a  localized  caseous 
state  of  the  pelvic  xya  1  follows  tuberculous  infection  of  the  kidnev 
Ihe  wall  becomes  thickened,  n.Klular,  caseous  tubercles  coalesce,  and' 
the  H'lvic  cavuy  become,  merely  one  compartment  more  of  the  multi- 
ocular  caseous  kidney  (tuberculous  pyelonephrosis) .  Perforation  of 
the  wall  IS  provided  against  by  the  consi.lerable  thickening  that  it 
undergoes. 

Parasites.-  Parasites  infesting  the  kidney,  and.  therefore,  the  pelvis 
and  ureter,  are  not  commonly  found,  but  echinococcus,  cysticercus. 
mana  sanpmus,  and  eustrongylus  figas  may  be  mentioned  among  those 
tnat  nave  l)een  found. 

Progressive  Tissue  Changes.- Tumors.-Tumors  of  the  ^vis  of 
the  kidney  and  of  the  ureter  are  rare,  \illous  growths-papiUoma- 
are  the  most  common,  and  are  apt  to  give  origin  to  serious  hemorrhage, 
sarcoma,  carcmoma,  and  teratoma  are  seen  occasionally 

Cysts.- Following  chronic  inflammation,  the  wall  of  the  pelvis  or 
irre ter  (,,r  even  that  of  the  bladder  and  urethra)  may  exhibit  liiimerous 
small  pinhead  c.vsts,  containing  watery,  yellow,  or  even  brown  fluid, 
ihe  trig<,,:e  of  the  bladder  shows  the  best  examples.  There  is  with 
these  (.ysts  some  epithelial  proliferation,  ami  the  conditi..n  is  known  i.s 
pyelius  or  ureteritis  cjrstica. 


i 


THE  BLADDER 

Congenital  Anomalies.- The  bla.l.ler  may  be  absent,  the  uret.rs 
openmg  into  the  urethra.  <.r  the  bla.l.ler  an.l  rectum  mav  fail  to  '.<■ 
sei)arate.l  ..rnimg  a  <'U„w„.  Septa  .)f  the  bla.l.ler  may  exist.  Extrophy 
".  *•?'■  f;l«"l''r.  the  in.)st  .inp..rtant  anomaly,  is  seen  when  the  two  lialws 
ot  the  b.).ly  have  h.ile.1  to  unite  along  the  mclian  line;  the  postci-.r 


THE  BLADDER 


62o 


wall  of  the  bladder  lies  .,pen  to  the  air,  the  pubie  bones  often  Ivine 
M.pnrated  by  a  considerable  spaee.     Freque,   iy  there  is  also  wi  h"f 

■:';;\Tt;be  w7*Tr"'^'^  ^a  ^''^'  ^"^"'^"•"  "^  '"^^^  bladder  th;ou;h 

fi,h;iV\.K  ihe  "rachus  may  remain  patent  (yeslco-umblUcal 

fisJJa).  or  hy  .m,,erfe>et  closure  urachal  cysts  max  be  caused 

Circulatory  Disturbances.-Hyperemia.-Active  hvperc^n  a  occurs  as 
.  sta^c  of  mflammation,  and  may  exist  without  developin/further  in 
rases  where  the  ur.ne  is  irritating,  by  reason  of  exccisive  aciHtv  i? 
tl.c  presence  of  certam  chemical  substances.  Passive  congestir  affec 
.n.'  .specmlly  the  tngonal  region,  accompanies  gcnerul  svLS  ~s. 
...n;  UHlema  ,s  a  frequent  accompaniment.  Hen,orrhage  in  the  form  of 
..•tech,a.  ,s  seen  m  cases  of  cystiiis.  new  growth,  and  those  steteT  Tn 
"Inch  ,t  IS  found  „,  the  serous  an.l  mucous  membranes.  Ilemorrhai^ 
...winch  .nuch  bloo,|  is  effus^l  is  generally  due  to  new  grovv  h^r'tonf 

.Vrtinr^r;    '^^"*t "'^'^  -"-  •»•  -tension  li  inSmmaS 
Irom  the  ureter  or  urethra,  or  as  a  result  of  abnormalities  in  the 
.-...tents    v.^.,  the  presence  of  stone    or  decomposing  uri,  1        areh 
..■  .nfeCon  is  hematogenic-.     Of  all  these,  the  most  potent  cause! 
f !..■  rc.tent.on  ot  unne,  the  distended  blad.ler  being  less  re  istan   thTn  the 

.f    mtate  the  wal  ;  n.  th.s  state,  a  .lirty  catheter  mav  intro,luce 

-  nrga,„s„,s,  or  waslnng  n.ay  wash  ba<-k  the  urethral  c-ontents  or   he 
I'l' '< '< I  may  carry  the  necessarv  germs. 

Tl.c  "rine  is  liable  to  un.lergo  fermentation,  alkalinity  being  produce.1 
\     tl  c  action  of  the  m,croaH-a,.  urc^.     It  is  bv  no  means  necessar 
tl.at    he  unne  n.  cystitis  be  alkaline;  indeed,  numerous  ca.-   arr^,w 
M  |.orted  ot  cystitis,  with  acid  urine,  due  to  the  B   coli 

Acute  Cystitis.     Catanhal  cystitis  is  a  comparatiA-ely  mild  attVctinn 
j-    .t  .s  notable  that  the  bladder  wall  at  au'topsy  mav  shl  ll;,^ 
"     '•'  ..ake,l  eye,  although  the  existence  of  the  inflammatio    be Ke 
'I. -.tl.  was  undoubted.     The  mucosa  may  be  faintly  redden^?   r  wd tn 
S-naiy  around  the  trigone.     .\  suppurative  staie,  however,  sSh' 

:i'  "in."  £™',t.i:'z;;: ' "-  ""■''  -'"""  »'• «- « '-- 

Chrome  C^BS..-A  sliRht  act,,  cvrtitis  may  ,„f,i„  i,„u.fi„it,.lv  nn,l 
t 'ir,;,,;'''"''  ''.""■'"'"'•  "'I'l  »<>■"«""«  ■«ntra,„,l  and  r  , ..T™ 


02C. 


THE  VlilSAHY  SYSTEM 


Tuberculosis.-  1  hv  i,i„st  fm|iioiit  mumIc  of  infection  of  the  bladder  h 
tiilHTculosis  IS  l)y  tile  passi.jre  of  l)a(illi  from  the  Ividnev ;  this  is  evidence 
by  the  frtHiueiicy  witli  which  a  tiii)ercu!oMs  ulceration  of  the  hladdi 
wal  at  a  .ireteral  orifi.e  is  seen.  Xotwithstandin^  this,  tlie  health 
bladder  wall  can  resist  the  attack  of  the  bacilli  for  a  c.nsiderable  tiin, 
but  a  preexistiuK  cy>titis  of  any  (krnr  will  lessen  this  power.  Pro. 
tatic  tulHTculosis  IS  also  able  to  infect  the  bladder.  The  disease  i 
seen  as  nnhary  tubercles,  each  ^rey  nodule  surroundeci  by  »  snia 
zone  of  hyperenna  where  tlu-  bladder  is  infected  as  part  of  a  generalize: 
tuberculosis,  or  occasionally  where  the  bacteria  from  nearby  sites  hav 
been  we  I  distributejl  in  the  uriiu-.  or  by  extension  from  a  caseous  foci. 
m  the  bladder  wall;  more  frctiuent  is  the  localized  caseous  lesion 
rapidly  ulcerating.  This  arises  by  the  coalescence  of  small  tubercle^ 
ami  tends  to  spread  oyer  the  mucosa  rather  than  deeply  into  the  wall 
The  caseous  material,  constantly  waslici  away  by  the  urine,  may  no 
be  eyident,  and  the  ulceration  may  be  mistaken  for  a  simple  one' 

Syphilis.- Gummas  of  the  trigone  haye  be(n  obscryed,  but  syi)hili 
of  the  bladder  is  Aery  rare.  ' 

Bacteria  and  Parasites.  iJacteria  are  freq..entl\-  fou.id  in  the  urine 
the  micrococcus  urea  seems  to  be  a  constant  inhabitant  of  many  healtin 
bladders.  1  athogcmc  bact.-ria  of  all  sorts  are  founrl,  whether  passe." 
through  a  healthy  kidney  or  not  is  .lebatable.  Yeasts  are  found  i. 
the  urim>  o  diabetics,  and  sometimes  of  healthy  persons.  AmoiiL 
parasites  all  thoM.  referre.1  to  as  being  found  in  the  kidney,  pelyi« 
of  the  kidney,  or  ureter  are  naturally  also  found  in  the  bladder,  added 
to  which  are  the  .gg.s  of  liilh„rJn  hcimiohium  escaping  through  the 
mucosa  (if  the  orj;;in. 

Abnormal  Contents.  i{lo,„|  corpn^.Ies  .,r  ,Hginents  api)ear  in  the 
bladder  urine  in  some  ca,es  of  nephritis.  i„  ulceration  of  the  tract, 
111  the  hem<.rrhagic  diseases  and  in  cases  when'  there  is  a  neoplasm 
Desquamated  epithdinin  from  the  bladder  or  any  higher  part  of  the 
tract  IS  seen,  as  vvell  as  casts  of  all  kinds,  an. I 'foreign  bo<lies  that 
haye  been  intro.lucc.l  by  th,.  urethra.  Laxly,  .ahnii  of  yarious 
s..rts  are  t.,und  ri.-  a.id.  nrat.^  or  oxalate  stones  may  be  pas>e.l 
•lown  troll,  tl...  ki.lney,  a...l  may  form  the  nucleus  for  phosphatic  or 
other  d.p..si!.  I-oreign  bo,li,.s  or  mass.s  of  cpiTheliun.  may  likewis,. 
lorrii  a  nucleus  tor  i)urc  phospha.ic  >toiies. 

Regressive  Tissue  Changes.  Atrophy  of  the  l.la.l.ler  occurs  in  ..1.1 
age.  as  well  a.  ...  .some  ca^.'s  of  a.lvanccd  cacl...xia;  the  muscular  tissi.e 
becomes  git-atly  l.-ssencl,  ainl  th,.  wall  may  be  of  extreme  tliinn<...s. 
!>istrn  -on  h.i.g  .■o..fn.,.,..l,  is  ah!.,  t..  I.rinu  about  the  conditi.m.  The 
usual  .rliular  d..p-ncr  ,r,ons  ar<.  f...,.,.i  in  the  i.iucsi.l  c.>Ils:  widespread 
necrosis  usuali.  uct-urs  from  trauma  as  in  i)arturiti<m  <.r  from  the  pressure 
.it  an  unusuall.\  larg.  <  hIciiIiis. 

Progressive  Tissue  Changes.  Hypertrophy.  H\p,.rtrophy  of  the 
bla.l.iero(.(...rslreqi.,ntly  and  forms  .„.„f  the  c..nstai.tly-used  e.xdM.pies 
l»y  wl.ieh    'hypertroi)hy  to  oycrc.ine  obstruction"  is  illustrate.l.    It 


•-dfesafe?*: 


THE  BLAni)Kli~rrMnRS 


627 


•'■^..nn.  i„  the  product!. mfHst,;""^!^^!';  T  *'>«*  ^-^^  '«  als„  a 
"".i  firm;  the  trabecnk-  are  e    -^r  i  •*'''''''"  ''""  '"  thickened 

'"'wcen  the  trabecut  i.     h^  "/  '^''  '''"''''^''•i  *''*'  ^^-^l'  ■"«  thinner 

to  >ac,.„iations  c.r " t  h  r,e  ,    S  ^'X  '""'"'  ""*'  «'^''"^  "«« 
;"  tl...  fnndal  half  of  the  l>hMld  t  '         *"  **"'  "'"'*  ^^^  *°  "^^•"- 


i'lu    2'Jl 


Kpilh,  l„.iiia 


"1  the  blmlder  infiltratinR  tho  tnu«-l..  ,.„„t :  „ 
with  comnifii.itiK  invasion; 


l<.  rnnciT  ci'li»;  , 
•■•inncftivc  ii..»iio. 


muscle  tilircs:  ,/, 


>'« I.MSS  Mtfa,.|,„|   rr,  "  i .     :     T  ""^''  "  "■'<  >'l„.,,  „r 

'I sr,„v,l,s  ,;  v„;  ;„  ™     '  ,",'  ""•  "»  ;     '»""">  "••I  i"  <"i..r. 

"'■ ;■ »Hv.  .lu..:;;,,     '';,-"  r  i;;. »:  "— .  '-ii.v. 

<"iiiirrti\,.  (issue  .nr,.  ,  I  I  irM-iike  tuhior  consist  of  a 

^<"-  "f  thcS  ,,2  ™  l'  ^^^I'^T^  '"l''*'^''  o'-  '■"'""-,.  cell" 
''-•l"-tl,  seen  Tn  r  J  Iv, ,  n  '*'  .  "I  '^'"  '^""""-^ '  Rbromas  are 
Myo-nas,  angiomas  Ldenomll''"  Vf  "^'"."  '«■<'>""■'»?  '"^xoniatous. 
'^^'"  -l.m,|.  fUt    •  ,?  !  l"-"j>ahly  arisnijr  from  misplace.!  pro.- 

"'■'^   U    Hit    ,,.»,•  -*qnam.,us-c,.II,.l  varL-f/;  these  ir.mths 

prtaent.s  n„  marked  naked  eye  .liHerenees,  save  that 


628 


THE  IHISMiY  SYSTEM 


perhaps  the  majority  of  cases  of  sarcoma  show  multiple  growtl 
hecoiKlary  carcmoma  of  the  bladder  is  quite  commc.n.  in  view  of  t 
liability  of  neighboriiiK  organs  to  the  growth.  \iz..  the  prostate  t 
rectum,  and  the  uterus. 

Displacements  of  the  bladder  occur  frequentiv  in  the  female  as  ■ 
accompaniment  of  displacement  of  the  uterus  and  other  organs-  tl 
bladder  has  been  found  in  hernial  sacs,  and  we  are  acquainted  with 
case  m  which  a  diverticulum  of  the  bladder  was  removed  as  part 
the  content  of  such  a  sac. 


THE  URETHRA 

Congenital  AnomuUes.  The  urethra  nvax  be  absent  in  conjunctic 
with  other  grave  anomalies.  It  may  open  on  the  lower  aspect  of  tl 
penis  (hypospadias)  or  on  the  upper  side  (epispadias);  it  mav  have  m..i 
than  one  oi)ening.  or  may  open  at  the  base  ..f  tiie  scrotum  or  into  H 
vagina.     Obliteration  or  valvular  obstruction  of  the  urethra  mav  occu 

Inflammation  -Urethritis. -This  may  arise  by  uncleanliness.  froi 
toreign  ImkIics,  from  trauma,  from  calculi,  or  from  the  injection  of  ant 
septic  fluids,  but  of  all  cases  of  urethritis  overwhehninglv  the  nw 
are  <lue  to  the  gonococcus.  Gonorrlural  urethritis  is  nioVe  commo: 
in  males  than  in  females,  because  in  the  latter  some  other  i)art  of  th 
tract  IS  hkely  to  be  primarily  infected;  most  frequentiv  the  disease  i 
earned  by  coitus,  although  infection  by  means  of  infected  towels  o 
be<l  linen  is  possible.  The  gonoco«  i  in  smears  are  apt  to  be  in  the  pu 
cells,  although  they  may  be  outside;  it  has  been  found  in  the  conjunc 
tiva,  which  IS  very  liable  t(.  infection  by  the  gonococcus.  that  when  tlu 
pus  fails  to  show  the  gonococcus.  a  light  rubbing,  not  sufficient  to  re.l.!e. 
the  surface,  will  remove  the  superficial  epithelial  cells  in  which  tiu 
gonococci  are  often  abun.lant.  This  is  not  ordinarilv  mechaimallv 
possible  in  the  urethra.  When  it  is  sjiecially  nee.led  for  diagnosis, 
cultures  should  be  made;  of  late  \ears  with  improved  methtnls  the 
gonwoccus  IS  grown  much  more  easily  than  was  formerly  the  case. 

Karlv m  the  disease  the  surface  of  the  urethra  is  reddeiunl.  with  a 
catarrhal  secretion  which  rapidly  becomes  purulent.  l)esquam:itioi. 
of  the  superHcial  cells  follows,  and  sometimes  ulceration,  which  nun 
b  eed,  and  the  infection  may  spread  backward  to  the  prostate,  an.l  the 
bladder;  in  the  iemale.  the  vagina  may  be  affected  throughout,  unl  the 
uterus  sind  tubes  attacked;  not  infrequentlv  the  latter  become  .iis- 
eased  while  the  former  escapes.  In  the  femah-,  Bartholin's  glands  are 
certain  t.)  be  infected;  in  all  thes.-  out-of-the-waN  situations  the  iiitV,  tion 
may  remain  for  a  long  time. 

The  inflammation  may  become  chronic,  and  in  the  male,  at't(  r  the 
lapse  of  time,  the  secretion  becomes  scanty  and  less  purulent,  perhap-s 
only  cloudy  or  even  clear  to  the  naked  eye  (fleet).  In  the  proc.  ss  of 
healing,  the  fibrous  grinulation  tissue,  if  abundant,  is  apt  to  sul)si(le 


THE  i'HETHUA 


629 


ll-  airfare.  <!..■  »Zic,i  m»      ,,^5        '"  ""^"'  '"^"^'^^  -I 

«!..  r  the  LwoH  ;/  ,  ,^'T"°!  '"">'  """'  "<■"  "  !""«  Period, 
|.">tori(.;partof  theure  hra      s"tZl  T^  ^"'^  ^P*""  **  '«««*  the 

»<  ...iliarv  or  oai^u,  f^r  |„e  , '  ,h.  '''''°  ",  "f  .""«"""■  '^'"e  »«" 
l»rl,„ril„.trati  'P"'"''  °'  '"'e'"""  '"»"  «het 

"<  iirs  as  a  iH.lviM.ifl  mn«     r«,-L  i    ^"     "''"»"»  occasiona  v 

i^"  I'i.iK  th.  li^.  ,^  t\    ZIZT  "•^.'^"l"' P''*"^-^»t«  the  instrument  from 
"I' 'r,  i,  MM,.  1     ,,   weaH-n '?•  '"''  '''^P'^^^^V"?"  P«'"*  "^  't  latcrallv. 

-::  n::,;^;;:^:"ir^^'"'^^  dist«n.?:i:^^„S.t^\^^ 


rFFAPTER    XI 

THE  REPRODyCTIVE  SYSTEM 

THE  MALE  SEXUAL  ORGANS 

THE  PENIS 

ni«2°**"l^,  AnomaUes.  -TJie  penis  may  be  absent,  double,  or  hyp, 
Plastoc.  ^yh.ch  ast  ,s  found  in  cretins,  m  ptorchids.idiots^tc  T^ 
3rnn<lT::,lr"'f  k'*  ^-'-"^iv  phlmosed,  that  is.  'abnormi 
tiirnf  n-  '""^Vl  °^  ,'?""8  retracted.  The  important  malform. 
rL. ,  f  ^",i  f'>P»»«Pa.l.as  have  been  considered  with  the  urethrT 
nect^,^  ."^  ^^^'^^-^^^  valvular  heart  disease,  the  lax  on 
nee  t^^  e  tissues  of  the  penis  are  apt  to  be  the  seat  of  «dema,  the  corpoJ 
c-avernosa  becoming  enlarge.! ;  the  lax  tissues  of  the  prepuce  m^-al' 

;:  t  Tt'r^lr  •  '"'Vr^^  '^'-^^^  ^"••P^^^  ma^berme^Lkt 
M,  that  the  corpora  cannot  be  emptied,  with  the  result  that  chroni, 
c-ongesion  with  erection  (priapism)  results.     Bands,  s  rings  or  S 

Si':;')"''  *''  "^"?  •'■■'^■•^  ^""^^  ^«"«--  by  ;eason  of  the    >^ 
r.ction  and  consequent  great  congestion.     Hemorrhage  may  occn, 

hematoma.    ""'"       '^"  '"'^"''^  '^""^  *''^"'"'^'  ^'''^  thf  formation  ol 

Inflamnwtion  -Inflammation  may  att-K-k  the  skin  (dermatitis),  the 
prepuce   (balanitis  ,  the  glans  (posthitis),  or  the  corpora  (cavTrn^tL) 

Lr^iLTl^""''  *''^  PrP"^'^  '"''  f^'^"^  ^'^  ^««^ked  together Tb^^i: 
t^-ll^  •  *''%P'-^'^"*'«'  f^.  being  specially  liable  to  inflammation  from 

f  the  weliinrTT"''':™,*^^  ''"•^«™"'  P"^'  '"rt  «"d  urinary  salts. 
fL  1         "r^  ''^^be  parts  be  great,  it  may  be  impossible  to  draw 

esursle  «"T^  (Paraphim<«is)  Ulceration  and  even  gangrene  m  v 
[he  LZr?  'ir°"'  ''"'  subsequent  adhesions  of  one  laver  of 
sequel?    n  ■:"''  °u  "V'"^«tion  and  fibrosis  are  more  frequent 

aSce  s  f,r,?  T'""'-!!'  *t'  •"*'^"''°"  being  c.lo.se.1  in  may  lead  to 
siderabl.  :•'  ^'.'tb^^b.sequent  rupture  into  the  urethra,  or  a  co„- 

e  s^,tr«     r^       '"  '*•  *'""'•"*''•    ^•'P*'  Progenitalis,  connected  with 

vhi.h  TrSr  "'?■;"•  ""'"'•'^^  ^  ^""""P  "f  •'^'""»  vesicles  on  the  glans 
which  rupture  and  form  erosions. 

i,nn!^^;~J'"lP"'""'''''  '"'''•"  "^  ■'•'■'^bilis.  the  hard  chancre,  is  the  most 

on^h    n  •  "{'P^'«'"'«  f'^ee  weeks  or  more  after  infection. 

Til    P"'''"''*^^' "^■"'-  tbe  raphe,  on  the  corona,  on  the  skin,  or  even 

'  r    ;  "'''*'"■"•„   l^eginning  as  a  minute  vesicle  which  mav  rupture, 

thtrt  IS  generally  a  small  ero.sion  surrounde.l  by  a  reddish  i)or<ier.  the 


CHASCRE 


031 


•i  or  hypo- 
"tc.    Tlie 
ibnormally 
malforina- 
!  urethra, 
e  lax  con- 
he  corpora 
;  may  alsi 
le  blocked, 
at  chronic 
s,  or  rings 
>f  the  con- 
nay  occur 
mation  of 

ititis),  the 
lavemitis). 
r  (balano- 
ition  from 
lary  salts. 
e  to  draw 
jrene  may 
;  layer  of 
'  frequent 
r  lead  to 
or  a  con- 
cted  with 
the  giaiis 

the  most 
infection. 
,  or  even 

rupture, 
>rdcr,  the 


a  s„peTO,„l   iav"    ,  f  ,1.  "'     .'"  '"/"""■  '""  '!»«  M  infect 

Fia.  292 


^^-^ 


'^%^, 


^J.^^< 


--''uf;:;;S;h^;^*'''"  ''^,^^'''""«-  ««^«1  "fte„  by  bacteria. 
.  ourgrowth  of  the  mucosal  elements  the  condyloma,  which  is 
reat  tendency  to  u  ceriiti,,.,-  «„oii, /»«"!»,  wmcn  is 


^'■•rr,,.-  the  formVt^n'  J        .         "  '"  '''  ^''"'*''  '^^^'^'"'«  ^''t'>  much 
'"  'i'.   site  of  Tr 'Tmfrv  r^  ''"^  ""  ^P«^^''«'  '«'«tion 

--.itai^:.^=iors;;;lS:i^r  ^^  "^^'^-  *«  ^""°^  - 

hard  mre  just  described  is  the  chancroid  or  soft  chancre  or  soft 


(W: 


TIIK  lih:i'liOhr(TIVK  SYSTEM 


•K'y- 


sor^  a  non.sypl,iliti,.  soro  that  fr.-qnn.tlv  arises  on  the  iK'nis  cans. 
»ase,  on  «ln<h  there  may  l>c  a  nmnbrane.     It  is  oftenest  fniiiiH  .,n  . 

L  n  ■!:  1  I  *-  '™": '  ^'""^"'♦'••«J  that  many  fomm..n  pathoeeni, 
o7;'  ••  ''',"'\'":''  «'rta.nly  present  in  nearlv  all  cases  are  caS 
of    HKlucnp  the  les,on.     A  eha.KToi.i  «,„y  k-come  infeeled  whh  sn  ^ 

1   om     n     It  ^^"'**'"-*';;:'  t''r  ^•'•aneroid,  but  the  systemic  infect!  „ 
III  (K(ur  all  tlie  san,e.     The  chancroid  mav  lead  to  severe  balan  t  s 

ZnlT-       ^"'*^/""'  *•'«'  Pt'">«  "'ay  even  l)ecome  phagedenic  nhaire 
tutrek  b.<iffrrr  °"''  r  "■'■!'■  '?'"i"e  "■~«™»  >er.v  like'"" 

flauS  b?^?hl ;.  f  'r.'"''  **"  *'"'  *^'^'"'  "•■  P'-'-P"^^.  sometimes 

Sze      \  i.r,         ^     n      '  "  "^  *"^''*  P''^P"^*''  sometimes  reaching  a  large 

vere.fl    T'"'     •■•  '"•  '  "^^  ^'^"'^'^t^  "*"  «  «»^'-o"«  vascular  a fe 
oven. I  bj   squamous  epithelium,  the  core  often  branching  so  ahto 

easv      The  nLir  t.     /    ,    "  'liagnosis  from  carcinoma  is  n<.t 

un  ';s  ulceration     •.  *'  ^""'-V'"^"'^'^"  "P""  ^^e  subjacent  tissue. 

pro  ection   sSr       .r?  ^'f**^'"'  *''^  ""tgrowth  of  a  hornv 

Et  .?.,?«  ..  *'"'*  '""'•  ""  *^^"  •'^'^'"-  '"«>•  «'^^"'-.  Elephantiasis, 
phaS:  tt  s  nl'"''"^^^  *■?'"'=  '*  '"^>'  ''«  ^-ombined  with  ek- 
Sbe        T  In         ""'  '-'r'  ".'•■''/  *•""'"•  ^^■^'•^'""«  25  kilos  has  b..., 

o  ten  tie  sent  7V"7'-'l,''  ''"''^•^'  ''^  ^'"-"""^  *'««"«  «"d  is  of  course 
otttn  the  seat  of  marked  inflammatory  infiltration. 


THE  !•  HOST  ATE 


633 


""I»<'rta,K-e  is  c.n.si.loral.l...      '    „  j     v  i7.  t!    '     ■?"•"''•  '"  *'"^  ''' 
«rmvtl,s  just  .iescribed  ma   rr  r'"'"  """  ^^'•'•^>-  «"''  '^^'^atoid 

".Tty  growth  bo«i„,s  L,  s^,"  s  7  '  r  !  ''■"^•'"^:'*"^•  ^''"^  «  «•""" 
'--  that  .n„y  ennle  thn.  ^  tt  .. ,  «•' M  '"''•  '"™"'^''  '"^""""t 
Miiiss  contain  a  foul    whitish   T    '''•'"'•''•.""'  ""merons  fol.l.s  of  tht 

--lily,   the  surface  Cm  nnSnT"'''',',''  '""'  "''■''™^'"'=  «"-"r^ 

naturally  the  earliest  sitTextentZ^^A^^  ""'""""'   «'"'^<'-^   "^^ 

.->  well  as  endotheUomw  ar .  fo  ,  -^^anofc  a.ul  other  sarcomas, 

^vl.ile  of  the  iH-nignTr^Z  fiZm.T'"'"''-'  ^".'"'"-^ '"-^^  ""t  common 
.S.|.am>us  cysts  of  th'e  "Ci.  aX^nr?  "'"'  "^''^"'^  "^'  ''^•«"''>^''' 

Injuries  of  Penis.-Iniuries  of  t  J  •  ^'"■''"'  t-ncount  -re.!, 
luxation  may  occur  b>-  th^mai  ifr' ^  '^r."""  "  "'""^  '"  d«-<  Wpt.on; 
Tom  the  prepuce  and  c'^rTi  1„  ' '.f  *'"  "'■'^""  '»*"'■"«  «Wt.ed 
tluskinofthitrunk  theorTlLL,  •'  '".*''"*  '*  "'"""^  ^o  lie  beneath 
^^in.  P^acture.  chtfly  ru^  T  thf  cT'"*'  "'"  ""  ""P^^'  ^"-^- 
"ith  some  frecp,e,,cv  when  i  was  snnnfr  T'''''"''''  "*^^»"«' 
<-.lee  could  becur;d  by^Vlln^r-'irSg  th-'coS/'^'''''"'"  *'^^*  '^ 


THE   PROSTATE 


".':Tar„f?:nvs:;lt  '"?-"■  ^^  - -'  •■■•"■ 

I'lrculatory  Distorbaneoq  —  h„«-   "  • 

v.'^y  oom^miy  a  J:^%^.S^^:  :^:t;^  ^TTT'- 

'^  >.-..,  and  phlebolltbs  are  common  *^"  {"'"^t^t't'  P'^xus 

-^^^^^mltsi^ti""""-''  ^*'""*''  ''  ^-'-ho-al   infec- 
'■"  ""■  «lMui  tubuL    the    nfced::  '"^"''•^  ^"  ^''r  "-tl.ra.     He^inning 

;'-!•••  -"i  -'tipieai,s:s"^s;n,ifs;;i '"  *'- ^""""'"^"'^ 

"  tl,..  almost  entire  destruction  ITih  ..    """'♦'^"nt's  coalesce 

"'">  '"'PPen  into  the  b  a  1  'r  t  •/  ^rT""  ^^""■'"'•^'  ••^"  ^"  «»>«""-^'' 
!-^'"-itis  is  ."xc-eptional  v";"  i  ;;r  "^C!'  rV"^'/"'""' ''"''  ^"--' 
""".^  'T,  unconmion.      Chronic  't  ids        '""'  "^r^^'  '"  ''"'■t'''"- 

'"-  n.nlt  inc.,,nsi,ierahlefibro^s  an,n      f;^^^^^  •j,'^"^^  «lestructive  grade, 

Tuberculosis  of  the  prostate  tVarvfr"  '''"'''''""  "^  ^he  tubules, 

""ultiple  caseous  nodulis  vh  ch  ma  o  "^"'l!."'  "'r""""«  t'>^"  '"""  "f 
■'-I'  -lar.en.ent.     The  /ZlsTZgi^^^  '''^7'  ^^^^ 

"';'.^  >  I>i.rt  of  an  extonsiv  ■  nrotrenS    .1  '    "'"''"'  ^"•'  ''^  "^'a"-'.^- 

Foreign    Bodies  -  ^^r,ZJ    ^  11      f'^^'^ful'-sis. 


^ 


034 


THE  uh:i>H()i)itTi\h:  sysTK\f 


or  another,  are  f„un.l  i„  the  ,,rost«t..>  ,.f  a  n.ajoritv  of  el.h-rlv  u 
nirRt  ami      i  ty  hke  grai.  -se,-.|>.  when  th.v  are  i  ,filtrat«l  u.th  « 

='''K'r  1,"*  """"■■  ""••"•  '^'"■^'^"^z> "  .ill: 
::^S^:;^3:i;;;il';;-:."' "-" -■■ -«.-! 

fn.^*'^?"*^*'  ^''?"*  ^'**°«*»-     Atrophy  ,„rurs  i„  aln^ut  „„e  out 

M-ase.  or  the  r.rese.u-e  of  eoneretioos.  I,.  the  last  ..a,,.,'  S;  stn 
suffers  most  ..therw.se  the  ^latuhWur  ,H,rtio„  fX  .  ,  h»» 
ofrr"  ''  ''"  '"""'^'  «''^-  «"•'  "^   '"^  n>ithehr'are"l'^S 


Ki(!   2!W 


middle  lobe  of  pro.-ale;  h    «i.  ,.|v  l,v„     7    "   Tl  ,    ',".  ""      '  "'  "'"  '"■•■*'""■    "■  ™l"««'  "'"l"'^' 

mnse.is      of  ,  Z  ;   .      ''^'  ^'':'n'iy  .hstiMguishe.!  from  the  same.    The 

oUn  "  con  1  f  r'!-""'?'"""'"""t''»  "f  ♦»^'-'  "r'^^thral  part  of  (he 
S  hu,ertro>h  ,  ?^^  ''^''^^T'"  '^^"^'""^  Ronorrhcea  an.l  pros- 
iimummation  wi^  show  itself  in  several  wavs: 


•'l<l«Tly  tiH-rt 
tlif\  inuy  be 
(I  With  salts, 
ritfular,  with 
f  of  .tanli 
iitl  ordilat.d 
l«'H<iiiuii)att'(l 
ion  nmy  }k.« 
latt.r.  Ti..- 
iw,  and  has 

one  out  of 
«»n,  wasting; 

the  stn)ina 
Hill  hyaline 
•  sometimes 


THE  I'ROHTATE 


635 


o«tatc,  whii'fi. 
iruwi  ui,.|ul:ir 


•  riiiari:(- 
uali^tiaiit 
me.     Tlif 

OlltCOIlll' 

rt  of  tlif 

md  pros- 

uretliral 


...ay  ie^'?o';lt^otrSn    ''*'  '"""^'^  ?'  ^''^  P-t«tic  duct, 
^^^o„Kl^     .il«lcy.stadenoma  *"'*  '^^■'^'"    "  «>"'''*>■«"  o^en 

n.;:..^' t  :urp!;i:!;;ir:?';r  "^  ^t  ""'^•"-'  •-^«*-. 

^^i'l.  o.v.stic  dilatation  ^"""^™*'""  "^  t''^  Rlan.lular  epithelium,  often 

"<■  ".ay  fin.l  a  cwsiderab  rdSuse^*^      ""*  ''^,  connective  tissue. 
•"".''int.1  with  that  of  the  muscle         ''•' ''^T''"^"'  "^  '"""^tive  tissue 


't.n.i 


"TI  from  ailcnocarriunmo  «f  *u 

'»  "t  lumen  formation.  ''"  """"""^  ™r,inoina.ou8  growth  (r,, 


•troma  (a), 
with  mero 


''-this  „o.i„|e  or  ricfge   p^^^^^^^^^^ 

'''-'•'♦r  contracts,  obstSTh^or^r  t  T'  ^'  *  ^'^'^'^  ^'^^^^  the 
:'['";'/.on:  this  leads  trhTpertXhv  a^d  K^'  ""'"'^'^  ^"^  '"I^es 
'''"'•'•■r.  and  causes  a  bav  or  f    ^  ^-     1  ?>«iuent  dilatation  of  the 

""  '-'-H-  wh,?h  fail  titsr  • 'tw  "V" ''''  ^«^-*  P"t  of 

''-  'table  seat  of  bacterial  jrrowt7  mm  whTch  "*'"?'  ^"'^  bec^^nes  an 
•"■'  ''ntis,  ,,yelitis.  pvelonephrh  s  anrl  nv  k''*"'^'"^  inflammation, 
'"■'"  -'I  "rination  calls  "or  thfemlvS.     f^^T  ""^^  ^«"'t-     The 


Mini 


MICROCOPY    RESOIUTION   TEST   CHART 

(ANSI  ond  ISO  TEST  CHART  No   2) 


1.0 


1^  1^ 


140 


2.2 


2.0 


1.8 


^  /^ppuEinjvHr  E   inc 

^^  -655    tast    Main    Street 

—J  Rochesler.    New    fofk  U609        VSA 

^Si  ■  ^16)    *82  -  OJOO  -  Pt^nne 

5SS  :  '16)    288  '  5989  -   Fa. 


(130 


'tut:  Jtt'PiiuDicriVE  system 


It' 


for  in  the  normal  jjrostate  of  early  life  it  is  non-existent.     Hy  most  it 
is  regarded  as  an  ontfrrowtli  from  one  or  other  hiteral  IoIm-. 

Tumors.--Of  malifrn  nt  jjrowths,  carcinoma  is  the  most  important, 
ocenrrinj;  as  a  primary  neoplasm,  and  not  infre(|iiently  in  a  gland 
previojisly  enlarged.  We  have  observed  one  ease  in  which  urinary 
ohstruetion  with  enlarged  jirostate  existed  for  eleven  years  before  tiie 
devel()j)ment  of  an  adenoeareinoma.  I'sually  it  is  soft,  nodular  in 
one  or  both  lobes,  and  spreading  rapidly,  it  infiltrates  the  "eapsule"  of 
the  gland,  the  mucosa  of  the  bladder  and  the  prostatic  urethra,  or  may 
go  through  to  the  rectum.  Microscopically,  it  consists  of  cylindrical 
or  polyhedral  cells,  arranged  in  an  attempt  at  glandular  formation  or 
in  solid  masses.  Metastases  are  not  a  markwl  feature,  and  happen 
first  in  the  retroperitoneal  nodes,  although  in  some  cases  there  is  a 
peculiar  liability  to  form  secondaries  in  the  bones.  Sarcoma  is  infre- 
quent in  comparison  with  carcinoma,  but  occurs  in  childiiood,  sometimes 
as  one  constituent  of  a  mixed  tumor.  Secondary  tumors  rarely  attack 
the  prostate  by  metastasis,  but  may  extend  from  the  bladder  or  the 
rectum. 

COWPER'S  GLANDS 

These  small  bodies,  lying  behind  the  bulb,  are  liable  to  inflammation 
by  extension  of  processes  that  originate  in  the  urethra,  and  rarely 
to  cyst  formation  from  blocking  of  the  duct. 


THE   TUNICA  VAGINALIS   TESTIS 

It  will  be  remembered  by  the  stmlent  that  the  testis,  primarily  in 
the  abdominal  cavity,  descends  into  the  scrotum  along  the  inguinal 
caiuil.  In  this  descent  it  pushes  before  it  a  prolongation  of  the  perito- 
neum behind  which  it  comes  to  lie,  and  along  with  this  there  is  pro- 
jected a  p()rtion  of  the  muscular  wall  to  form  the  guhernaculum  testis 
together  with  associated  vessels  and  nerves.  Folhiwing  this  descent, 
the  j)rocess  of  the  peritoneum  becomes  normally  closed  off  from  the 
IJcritoneal  cavity  proper.  Xon-closure,  with  persistence  of  the  inguinal 
canal,  favors  subsequent  hernia.  Tht'  testis  thus  lies  suspended  behind 
a  peritoneal  sac,  one  wall  of  which,  in  juxtaposition  to  it,  forms  tiie 
visceral  layer  of  the  tunica  vaginalis  testis;  the  other,  the  parietal 
layer,  is  separated  from  the  skin  of  the  scrotum  by  loose  tissue  con- 
nective tissue,  in  which  is  the  cremasteric  muscle."  The  visceral  and 
I)arietal  layers  enclose  a  .sero'is  sac,  and  this  serous  sac  may  show  all 
the  conditions  seen  in  the  <»ther  serosa.'  of  the  body. 

Abnormalities.^In  the  preceding  paragraphs  we  have  already 
referred  to  these,  viz.,  the  patency  of  the  neck  of  the  sac. 

Inflammation. — There  may  be  a  certain  amount  of  anasarca  of  the 
tunica;  of  greater  importance,  liowcver,  are  the  collections  of  fluid 
resulting  primarily  from  inflanunation,  viz.,  the  condition  of  hydrocele. 


rilF  TESTES  AXD  EPIDIDYMIDES 


(W7 


litre  It  IS  held  that  the  first  stage  is  a  serous  periorchitis  resulting  in 
.  isteiition  of  the  sac  by  a  clear  serous  fluid,  and,  once  accumulated, 
the  tendt-ncy  to  secrete  fluid  is  maintained,  so  that  tapping  is  often 
toi lowed  by  reaccumulation.  In  more  acute  inflammation  the  fluid 
may  he  blood-stauied  and  the  exudate  of  a  seroHbrinous  tvpe  with 
<lei)osit  of  a  membrane  over  the  testis.  In  gonorrheal  and  traumatic 
cases  there  may  be  a  purulent  periorchitis,  but  acute  periorchitis  of  a 
hbruious  type  without  marked  fluid  exudate  mav  occur.  It  is  not 
uncommon  to  find  at  autopsy  old  fibrous  adhesions  between  the  two 
walls  of  the  sac  indicating  such  old  inflammation.  Reverting  to 
li,v(lrocelc,  it  deserves  note  that  in  a  considerable  proportion  of  cases 
no  liistory  can  be  obtained  bearing  upon  any  primarv  trauma  or  infec- 
tion. Ihus  the  etiology  of  the  condition  is  not  whollv  worked  out 
111  old  collections,  the  hydrocele  fluid  may  appear  shimmering  from 
niiiiierous  plates  of  cholesterinc. 

Syphilis  and  tuberculosis  may  involve  the  tunica  bv  extension  from 

tlif  testis. 

Progressive  Changes.-  Tumors  primary  or  secondarx ,  save  by  exten- 
sion from  the  testis,  are  distinctly  rare. 


THE   TESTES   AND  EPIDroYMTOES 

Congenital  Abnormalities.— It  will  be  remembered   (Fig.   141    p 
INS)  that  the  epididymis  and  testis  originate  fr    ii  two  separate  bodies 
tlic  former  coming  to  constitute  what  may  be  termed  the  collecting 
tubules  for  the  latter  and  that,  owing  to  imperfection  in  the  junction 
Ixtwcen  tiie  two  parts,  certain  orders  of  cysts  may  develop.    So  also 
It  may  be  recalled  that  in  development,  adrenal  tissue  mav  be  snared 
ntl  aiKl  earned  down  along  with  the  descending  testis.    As  regards  the 
testis  Itself  there  may  be  various  grades  of  lack  of  development  or 
liiiiure  to  attain  the  normal  position  in  the  scrotum.    There  thus  mav 
I'c  absence  of  both  testes— anorchidism,  absence  of  one  testis— monor- 
chidlsm,  non-descent   into   the  inguinal    canal— ciyptordUdlsm,  dupli- 
<^iti<m  of  a  testis— polyorchidism,  or  fusion  of  the  two-synorchidism 
Hypoplasia  or  incomplete  development  is  met  in  cryptorchidism  and 
"tli.r  tonus  of  dystopia  or  failure  of  the  organ  to  pass  into  the  scrotum- 
m  .rctinism  and  other  cases  of  delayed  or  imperfect  development' 
I  litre  may  be  v.-nous  grades  of  dystopia,  the  testes  being  found  in 
'■'•  nt'ar  their  pnmordial  position  in  the  neighborhood  of  the  lumbar 
y  rt(  hra-,  in  the  pelvis  or  imperfectly  descended  in  the  canal,  or  again 
'l|  nut  may  be  not  into  the  scrotum,  but  into  the  tissues  of  the  inside 
"I  I  lie  thigh.    There  may  be  not  only  congenital,  but  acquired  dvstopia 
:>^  "(curs  occasionally  after  trauma,  the  testis  being  forciblv  displaced 
■/•■■m  Its  site,  usually  uj)  the  canal.    Very  rarely  both  testes  have  been 
'"I'i'l  111  the  one-half  of  the  scrotum. 

Aspermia.     .\bsence  of  discharge  of  spermatozoa  in  the  adult  mav 
''  'liH'  to  0)  lack  of  production  in  the  testis,  or  (2.)  to  stenosis,  obstruc- 


().*?S 


THE  HKPRODUCTIVE  SYSTEM 


n- 


tion  or  destruction  of  the  vasa  deferentia  as  the  result  of  trauma 

inflammation   or  new  growth.      Prolonged   obstruction   to  discharge 

leads  eventually  to  atrophy  of  the  epithelium  of  the  tubules  of  th( 

testis,  and  so  in  certain  cases  both  causes  mav  be  ()|)ei     ive.    Deficieiil 

production  of  si)ermatozoa,  with  consequent' sterilitv  .m.\  be  brouKliI 

about  by  many  causes,  some  congenital,  some  acquirea.    Thus  aspermia 

IS  encountered  where  :he  testes  are  retained  in  the  abdominal  cavitv 

even  although  apparently  fully  formed;  for  a  few  vcars  around  the  age 

of  twenty  it  is  stated  that  such  cryptorchids  may"  present  spermatozoa 

in  the  semen,  but  after  the  age  of  twenty-four  they  are  uniformlv 

found  sterile.     Imperfect  de'-lopment  of  the  testes  has  also  associated 

with  It  aspermia  or  oligospermia.    Such  hypoplasia  is  frequent  in  cretins 

accompanying  defective  development  of  the  thvroid;  in  acromegalic 

giantism  there  is  a  similar  aspermia  and  lack  of  sexual  capacitv     In 

the  very  obese,  men  and  animals,  aspermia  shows  itself,  passing  off 

with  reduction  of  the  olwsity.    (Jeneral  lowering  of  vitality  as  bv 

long-continued  disease  and  after  excesses  of  various  kinds,  including 

mental  worry  and  overstrain,  lead  also  to  lack  of  development  of  the 

spermatozoa. 

To  the  contrasted  condition  of  precocious  sexual  maturitv  we  havp 
already  referred  (p.  102).  ' 

CircuUtory  Disturbances.- The  only  serious  circulator',-  disturb 
ances  are  traumatic  hemorrhage  and  the  se<!oiidarv  effects  of  arrest 
of  circulation  as  from  thrombosis  of  the  pampiniform  plexus 

Inflanunation.- Inflammation  may  be  either  ascending,  along  the 
vas  deferens,  in  which  case  the  epididymis  is  first  affected,  or  hemato- 
genous when  the  body  of  the  testis  is  more  liable  to  be  involved     Most 
often  both  testis  and  epididymis  are  implicated.   The  most  frequent'form 
of  inflammation  is  that  due  to  the  gonococcus,  and  here  there  is  first 
a  catarrhal  epididymitis  followed  by  a  more  interstitial  orchitis     The 
epididymis  becomes  enlarged,  tense,  and  painful,  on  section  is  found 
congested,  showing  tubules  distended   with   semifluid   exudate      \t 
times  this  passes  on  to  actual  abscess  formation.    The  testis  similarly 
becomes  firm  and  painful,  and  there  is  a  similar  catarrhal  exudate  ill 
the  tubules  with   an  accomnanying  pronounced  cellular  infiltration 
of  the  stroma.    With  arrest  of  the  acute  condition,  fibrosis,  shrinkage 
and  atrophy  of  the  organ  ma;   supervene,  if  the  inflammation  has  been 
long  continued.     The  type  example  of  hematogenous  orchitis  is  seen 
in  mumps;  at  times  this  complicates  other  acute  infections,  e.  a.  small- 
pox and  typhoid.  ' 

Infective  Granulomas.  -Both  tuberculosis  and  svphilis  are  apt  to 
affect  these  organs.  In  tuberculosis,  more  often  the 'infection  is  ascend- 
ing and  as  a  result  the  epididymis  is  apt  to  be  the  eariier  and  the  more 
involved.  The  discovery  of  an  enlarged  epididymis  mav  be  the  eariiest 
clinical  sign  of  the  existence  of  tuberculosis  in  the  bodv.  There  is 
formation  of  relatively  large  caseous  masses  with  extensive  destruction 
of  the  tissue  of  the  organ  and  progressive  extension  of  the  process  along 


THE  SCROTUM 


639 


the  tubules  into  the  testis.    If  the  process  reac-hes  the  tunica  vaKinalis 

In  contrast  to  this  the  most  frequent  form  of  svphihtic  imDhcation 
.nvolves  the  testis  pro,>er.  as  a  .iiffuse  fibrosis,  'the  so^alTed   white 
swelhng.     Less  frequently  definite  gummas  develop.     In  the  former 
,o,Kht,on   he  testis  beco„,es  enlarge.!,  hard,  and  insensitive  to  pressure 
hn.akdoll        •  "  "'*'^  ^"'--ulosis,  the  skin  may  be  involved  and 

Regressive  Chamres.-Simple  atrophy  of  the  organ  with  aspermia  is 
.  s.  „le  change  and  occurs  in  marasmus  and  wasting  diseases  aTak, 
as  t  u.  resul  of  the  influence  of  ;r-rays.  Pressure  atfophy  1"  d  n 
...m^itions  of  hydrocele,  hernia,  and  neoplastic  growths 

Progressive  Changes.-Hyperplasia.-Cases  of  precocious  develon 
n.ent  and  .naturity  of  the  testes  have  been  noted  partSaly  in  con! 
nect  on  with  hypertrophy  and  tumor  formation  of  the  adrenal  cortex 
In  tlie  adult  there  .s  httle  evidence  of  compensatory  hypert^phy  after 
"'vl^yjoung  ""'""  "'  '^"^  "'  '•^^  ^^''  though^this  mToc'cur  in 
Tumore.-Tumors  of  the  testis  are  not  uncommon;  thev  are  char- 
ajtenzed   as  a  group,  by  rapid  growth  and  malignancy.    The  varktv 
ot    orms  described  is  bewildering.     Recent  careful  studies  of  several 
•rtions  from  various  areas  in  such  tumors  are  leading  to  the  conclu 
.on  that  the  maj(mty  are  of  teratomatous  nature      Severafca  es 
are  now  on  record  of  chorioH^pitheUoma.    \ery  frequentlv  we  encounter 
m.xed  tumors  wrth  glan.lular,  cartilaginous    sarcomatous,  andothe 
tissues.    In  addition  we  may  find  tumors  of  simple  type;  it  seems  that 
pun  sarcoma  may  originate  from  the  interstitial  cells  of  the  test's  and 
ha    pure  caicmoma   occurring  as  it  does  in  adult  life,  may  or  ginate 
tron.  tl„.  tubules  ot  the  organ.     Other  cases  of  so-called  ca/cSoma 
sarcomatodes  are  explicable,  when  it  is  remembered  STat  the  tSS 
jpi  iH  unn  IS  of  mesothelial  origin,  and  that  therefore,  we  wou  Wexpect 
t"  fiiKl  transitional  mesotheUomas.  expect 

Cysts.  We  have  already  referred  to  the  congenital  cvsts  and  it 
•Mianu  only  to  note  the  spermatocele,  a  relativeh  large  .'IfOrfdna 
.  apparently  from  aberrant  tubules  of  the  epididvmis  which  under 
<■  .MHuonce  of  some  ..bstruction,  may  become  of  rdativelv  gr;at  size 
.^n..ng  into  the  cavn,  of  the  tunica  vaginalis  testis  and  simulat Tng 
I'.v'irocde.     Ihis  on  puncture  affords  a  fluid  containing  spermatozoa 


THE   SCROTUM 


i       ..ic     h.    F    "^  '^^  scrotum  are,  broadly  speaking,  those 

^     ,.n    md^f       /  .'"  ^'T^h  ^"*^  '''"^^•"  modifications  due  to 
1      t. o  .  .u„,  th,  ,,,  ^,^.^  abundance  of  its  con,stituents.    Thus  the 

""*"=  ^""^'""^  dislUictly  contractile  cremasteric  muscle  fibres 


It 


()4(» 


TIIK  RKPROmCTIVE  SYSTEM 


juul  there  is  a  lack  of  siilKMitaneons  fat;  it  is  pe.uiiarlv  liable  to 
involved  III  elephantiasis,  and  then  may  attain  a  hii^e  size  Its  v 
(Ularity  favors  hemorrhage  in  trauma  and  in  obstnutive  heart  disea' 
in  renal  disease,  oedema  may  be  extreme.  Vf  tumors  the  most  importa 
IS  carcinoma  (squamous  epithelioma),  apparently  secondary  to  irrit 
tion.  In  the  old  days  chimney  sweeps  were  peculiarlv  liable  to  tl 
forrn  of  cancer,  and  today  workers  in  tar  and  paraffin^how  a  simil 


THE  SPERMATIC  CORD  AND  VESICULiE  SEMINALES 

Especially  in  those  haviiiR  a  long  spermatic  cord  the  accompanvir 
veins  of  the  i)anipiiiif(,rm  plexus  are  liable  to  varicositx-,  and  as  the' 
are  relatively  abundant  they  may  form  a  tumor-like  mass,  varicocel 
This  IS  found  more  frequently  ,m  the  left  side  ir  -onsequence,  it 
held,  of  the  course  of  the  vein  on  that  side,  which  ren.lers  it  more  liabl 
to  pressure  and  obstruction. 

Mammation  of  the  yas  deferens  occurs,  not  as  an  isolated  conditioi 
but  in  association  with  epididymitis  and  vesiculitis;  as  a  result  ther 
may  be  a  reparative  fibrosis  leading  to  blockade  of  its  lumen  and  consf 
quent  sterility.  Hepirdum  the  vesicu'a'  seminal. ..  there  has  been  som 
debate  as  to  whether  these  are  to  be  repirde.i  as  reservoirs  for  th 
sperm  or  as  aflordm-  a  special  secretion  for  admixture  with  the  same 
Apparently  in  man  thev  have  the  .louble  function.  Inflammation  i. 
Its  active  state  may  lead  to  marked  tumefaction,  and  subsequently  t( 
hbrosis  and  contraction.  As  to  its  causation,  th,.  gonococcus  is'th. 
most  frequent  intectinK  ajrent,  though  pure  strepiococcus  infections 
also  occur.  Tuberculosis,  both  ascending  and  descending,  may  involvt 
these  and  the  vas.  '' 


THE  FEMALE  SEXUAL  ORGANS 


THE   EXTERNAL   GENITALIA 

Abnormalities.  Th'Te  is  a  long  list  of  abnormalities  of  the  external 
genitalia,  inv(.lving  either  indivi.lual  parts  or  the  whole  tract.  Of  tlie 
entire  tract  there  may  be  complete  ai«ence  as  in  certain  monsters 
'>;R"I*."^."|  "-^  '"  cretinism  aiul  other  forms  (.f  incomplete  development. 
Ot  induK  ual  parts  the  vulva  may  be  abnormally  small;  the  cUtoris 
may  he  absent  or  hyperplastic,  us  in  some  cases  of  false  hermapl.ro- 
ditism,  or  double,  .  as  the  lowest  grade  of  inferior  duplication,  or 
adherent  o  neighboring  structures.  The  labia  may  be  ahnonnalh 
small  or  abnormalI\-  larr  ;  the  labia  min..ra,  as  a  congenital  condition 
or  as  an  a,(iuireinent,  may  be  of  great  siz.-  ^Hottentot  apron).    The  ImIm;. 


THE  eXTEHSAL  CE.MTALIA  841 

til.'  menstrual  blood  ^       '*^'  ^'"''^  ''*^^^'"I^^  "-^t^nti""  of 

disturbances  may  show  them  el  Xr"'    AHrtit   T'""'  'f"'*""' 

»i?'i.<as!o„allvaslui»i.  """""•'«'■     T«b.rciilo»s  is  rare,  apptar- 

tl"  -«l.c„taneous  tissue  of  117™,;!  «  h  I,  ^'°""'  ''>'<^'l>^^''  "' 
•l»  kin,  and,  being  general  resilltn  I  '"'^  '"''  """"''>•  "' 
"fllBuilvarOTifte    ^   """^'  '"•""'■  '"  «  l>K>gressive  contraetion 

.iSSV„^rro-;i^i^r«r',»  '-«  there  .nay  be 


M2 


THE  ItEPIiOmCTlVE  SYS       V 


r    3    •'  ,?'"'"""''^t  *'""•"•  *^»"  tl'is  r.gi„„.  an,l  .  a-n  then  not  v 
r.(,uent,  is  the  squamous-ceUed  carcinoma.     Melanotic  sarcomas  hi 

c^u  ^f 'II!  '  ■  .  "i"'*^  '■•'*''■  ^'*"""t'""S  most  common  are  retent 
cyste  of  the  glands  of  Bartholin.  A  rare  c>'st.  corresponding  to  sere 
hydrocele,  may  originate  from  tlie  canal  of  Xuck 


f 


THE  VAGINA 

The  vaginal  walls  are  n<.rmally  in  contact,  rugose,  except  in  t 
j:c«nd   after  frcqncnt  parturition,   sparsely   provided  . J  ,L 
ned  hy  squamous  ep.thehum.     Despite  its  sim,,licitv  of  .t„, 

tlie  yagma  partakes  ni  many  diseased  conditions  arising  in  it         nedii 
neighbors,   the  external  genitalia  and   the  uterus.      Its  .olatfon 

iZffT"''./'"' ;•'""•'  '''"''••'^'^-  -'•»""''«-'  the  viscera  in  Dough 
it  T  "'*^'^"f""r  "'.P-r'ti'!"  'lue  to  pressure  or  traction  exert, 
upon  It.  Ihe  yagmal  wall,  havmg  no  inherent  rigiditv,  is  liable 
become  n.yerted,  or  even  prolapsed  through  the  vulvar  Orifice,  ip, 
m^v^desi;^  r*""  '""""'  "T"'""'  '•""•^'  "''^""'^  themselves;  the  bladd. 
orw..r  X  ,  t''  """'  "n*"  '"''^''''''  (''y«*«"l«);  the  rectum  mav  pu> 
^ZeiL^^T  ""•  ''""  ('««=*«««»«)•  "■"!  lo'>P«  of  the  bowel  or  eve 
rJl  t  t"'  '''■''"''■  ■"'"'■  '''"■'■•"''•'^  "P'^"  the  passage  (enterocel 
ovanocele).    In  partunt.on,  and  otherwise,  the  wall  mav  be  injured 

cZ;tl--  'T  ^:''-'^'"  '-J'-  i"  fe-eat  variety  have  C  e 
CO  ntercln,  the  yagn.a  as,  for  example,  forgotten  tampons,  pessarie: 
and  objects  mtroduced  for  purposes  of  masturbation.    (  n  one  occasio 

M;^'imltVd*'r'"^V''"  '"^^t  '"'"  "^ "  ^^-^^-^"^^ «» >-'h  ^^^^ 

hi^fnr  .  n  '/*  "'  'n '  '""  "  '""^"^^'•"•'l*^  time.  Such  objects  remain 
Ahnn™  ,!•""'  "-^m''"- ■  ''''"'"^-  ""^ted  by  phosphates  and  carbonat<. 
Abnonnabties--  Ihe  xagu.a  may  be  absent  or  duplicated.     M..r, 

common  than  either  of  these  states  is  a  relative  narrowing  (atresil 

ctrTl'  '""'t  't  T  '"■  "'••'■'■  P""'t^'  '"•  throughout  the  tube. 

co„<r^,t^?n   "^  Disturbances.- In  the  later  weeks  of  prcgnancv,  passiv. 

SZ'«""''i    ."^'""•"h«g''  in  the  walls  is  usually  traumatic 

InflMmnatioil.-Vagimtis,   often   associated   with   vulvitis  as  vulvo- 

vagmitis  may  be  acute  or  chronic.    Among  acute  infections,  as  miKlit 

he  sui)posed,  gonorrhea  is  the  commonest.     An  acute  inflammatio,. 

irom  gonococcus  or  ,)ther  agents  ma>-  spread  from  the  vulva;  the 

discharge  of  acrid  or  infective  material  from  the  uterus  is  also  a  cause. 

Ihe  wall  IS  rcd.iened,  secretion  is  increase.l,  and  this,  at  first  catarrhal, 

later  becomes  purulent.    In  young  children  vulvitis  mav  .spread  to  the 

%agina,  in  spite  ol  the  j)rotcctive  hymen,  and  it  is  worthv  of  note  that 

accKlental  infection  of  infants  hy  gonococcus  may  readily  occur.    In 

cmldreii  s  hospitals,  a  case  of  vunovaginitis  is  so  liable  to  infect  the 

enure  ward,  that  it  must  be  cared  for  by  an  attendant  who  does  iM 


chondromas. 

leii  not  very 
rcomas  have 
ire  retention 
ig  to  scrotal 


oept  in  the 
lit*    glands, 
t    '  '  >?tiirc, 
nediate 
lolutions  to 
in  Douglas' 
tion  exerted 
is  liable  to 
fiee.    Tpon 
the  bladder 
1  may  push 
vel  or  e\eii 
(enterocele, 
;  injured  or 
J  been  en- 
!,  pessaries, 
ne  occasion 
n  diameter 
urroundinjr 
cts  remaiii- 
"arbonat's. 
ed.     More 
ig  (atresia) 
ibe. 

cy,  passive 
traumatic, 
as  vulvo- 
,  as  mi^lit 
ammatioti 
ulva;  the 
;o  a  cuu!;e. 
catarrhiil, 
;ad  to  the 
note  tli.it 
iccur.    In 
infcit  tlie 
does  iu)t 


THE  I  TK/ifs 


643 


n:i:d^:';h::^i:a,£S£.:^-  ---  ^^^^^^  ^--^^  ^andim. 

i-.t''ttion  in  .lebiHtS  suC  '  '•  T^'  "•"«"'»*^  '^>'  "  '"^  form  of 
.--bations  ovir^bn^S  leu^a)  'Vr'!?-  'l  ^''"^'  ^"«^* 
ut.rus  are  hert-  also  of  importance  h.T?!*^'  •  ^^'^ '''''^^"'•'^*'"  ^^  ^^^ 
I'HHl  result  is  hvpertrophTof  the  m.  '""*'?V'^'  *^"  Tritation.  The 
-r  papillate.  ev;n^tua  l^t  t  mes  TtSie  I  '•;  ""*'''  T^^"  «^*""'" 
of  inHammation  in  ne'k.v  or^s  Is  w  'ri  T"'''-  /^'  ^  '•^^"'t 
tk'  \agina,  flstula.  mav  be  fonS  «^«  f    ^  ^™""^  f''"'"  ^''thin 

It  is  notewortliv  tt.a/  !i  '•    ''*®^*«"**''  '"•  vesicovaginal. 

or>,v,^.iHtln:fons    '''  *'"  ^'^'^'"'^  '•«^^'>-  -^"^>ts  either' tuberculous 

'i '^'"c/^s^]iLir.:!;:e;^^^  f  ^'^r  -^'-  *-^  *° 

Progressi-e  Chafes -Tim.1     t       '   T{^''^'  ^'^^"™ng  smooth. 

"iixvd  tum;r.  encoltered  h,  chn.  ^*''  ''  ^^^  t^ratoblastomatous 
-l™»-.ts  along  S  3 "cell  t^J'  T'""'"''  ^""'^'^^  sarcomatous 
sarcomas  have%lso  \Z  ta,u^^J't  htZ  ,'"""''"^''  *'^^"^«-  P"""- 
"-.V  be  the  site  of  primarv    qumo'Jceir^  /he  vagina 

m-  prone  to  infiltrate  from  carci^^  ITu  carcinoma,  and  secondaries 
'.s  well  as  from  chorTo-'i^^^raTtfe^utr^^^  ''"''"'  "^  '^«*"'"' 


THE  UTERUS 

i'.■f!'^elmSa;d^itt'c^^..''   '    "'^;."'  P^^'-^aped,  but  flattened  from 

"f  plain  muscle  fibres,  '  '„o,^'.''™?""'V '"™^^''"  t''^ «"«"'. 

"f  its  extent,  and  a  muros      ht  enrS.  f  f'*™^"'  ^pvermg  over  most 

'Pitl-lium  prolonged"m^tbe  musdeTs  """?.'  'T'^*^"^  '^^  ^°'"'""«'- 
S-'lan.lul.r  acini.    These  dands  Z^L     «"  abundant  series  of  simple, 
'l"m  in  the  cervica  Irelon      Crr       'l'""^  ''^^°^«t«  «nd  abm.: 
'""  i'""K.diatelv  underMng  the  enirr  '^''^^y^^^^'^  submucosa, 
'I'anKterized  b^  a  rSvelv  abn.lnt       ""  '«,\ reticulated  stroma 
i"  Pa-ing  «e  would  note   must  not  J      "??f"'«t.on  of  cells,  which, 
;i"''-tion.  or  for  a  d^tTalmlt^rusTotS'  ^ V"  .'"^^-atory 
f-  >M.v,„„otrium  is  richly  vascular    anHYnVv.       ^^  "'"^''  '"'''^'"  ''^ 
tl'e^.•  v.ssels  show  the  evidences  of  i'nv  I  .•      **^«^ '""'t'Parous  woman 
i-m^lMTal  hyaline  change   tcMvhich  we  h"*'""  T'^  '^^^^  ^"™«*'""  "'th 
-^;  "'rther.  abun.lant  fvmp  mt^f  thie  o7tT      ''^  ""  ^^  ^^^^    ''^''"^ 
"'"'  '!'•'  iJiac  lymph  nodes     hose' of  t..  K  J     TV""  ^""""^"ieating 
'•""I'ar  .nd  inguinS  groups  '^'''  '"^  *^^  """^a"  ^"^h  the 

-.tS::^e?ndSt^^^^^  ---  ->■  '>e  n,ade 


If 


^1 


;l 


If'pf' 


644 


77/ A'  UKI'HOhlcriVK  SYSTEM 


ti. 


the  Miillerinn  (hiots  unite  into  a  rommon  cervix,  the  litems  i>  bic 
nuate;  there  may  he  two  cavities  enclosed  in  a  common  uterus  (ute 
•optus).  Coiisiderinp  the  juxtapositi 'H  of  uterus,  hhuider,  and  reef 
an<l  the  primitive  common  ch>a('a,  it  is  not  remark".l)le  tliat  iK-casiona 
separation  is  imperfect  with  resultant  uterovesical  and  uterorec 
fistula.  There  may  he  stenosis  of  the  cav  ity  associated  with  imj)erf( 
development  of  the  uterus  along  with  that  ol  the  other  K('»>talia. 

Congenital   Anomalies. — Two  great    classes  of    anomalies  can 
recognized,   tin-  dystrophies,   due  to  nutritive  ilisorders,   re.Miltiug 
ahnorniality  of  size;  and  the  dysplasias,  due  to  eccentricities  of  deveh 
inent.    They  may  he  associated. 

The  uterus  may  he  wanting  (aplasia)  or  diminutive  (hypoplasi 
and  this  may  he  symmetrical  or  asymmetrical  according  as  the  Miillcri 
duets,  which  form  the  organ,  are  equally  or  unequally  involvetl.  Ti ,, 
verse  fission  of  the  os  uteri  may  he  confouiided  with  that  resulting  fn 
childhirth.  Ileal  aplasia  is  rare,  for  nearly  always  some  rudimei 
of  uterine  tissue  are  to  he  found.  The  external  genitalia  are  genera 
intact,  but  the  ovaries  and  tubes  may  occasionally  be  absent. 

Where  one  Miillerian  duct  fails  almost  entirel.v  t'>  develoj),  1 
uterus  unicornis  is  formed.  If  the  ducts  fail  to  fuse,  uterus  didelpl 
results,  in  which  there  are  two  separate  uteri  and  vaginie,  or  two  ut 
and  one  vagina.  If  the  ducts  fuse  below,  and  not  above,  uterus  bicoi 
results,  and  modifications  of  this  are  seen  in  uterus  bicomis  dupl 
where  there  arc  two  complete  cavities;  if  these  unite  at  the  cervix 
have  uterus  bicomis  unicollis,  while  if  a  septum  divides  the  utcr 
cavity,  the  condition  is  called  uterus  septus  or  bilocularis,  and  there  i 
names  to  distinguish  the  various  degrees  of  completeness  of  the  septii 

The  cavity  of  the  uterus  may  be  absent,  or  there  may  be  mniti 
rudimentary  cavities;  it  may  be  narrower  than  normal  or  obstruct 
(stenosis  uteri),  or  it  may  be  in  communication  with  the  bladder  l)> 
tube,  or  with  the  rectum  (congenital  uterorectal  fistula;  anus  uterini 
The  uterus  may  fail  to  develop  beyond  its  foetal  state  (uterus  foetal 
or  beyond  its  infantile  state  (uterus  infantilis).  On  the  other  hand, 
may  develop  precociously.  Occasionally  at  birth  the  uterus  is  f  fii 
retroflexed,  in  varying  relation  to  the  cervix,  retroverted,  or  anteflex 
It  has  even  been  found  in  an  inguinal  or  crural  hernia  (uterocele,  h 
terocele). 

Acquired  Abnormalities  of  the  Uterus.— The  pressure  of  tumors.  Hi 
or  organs  misplaccil,  or  traction  in  unusual  directions  or  its  own  wcij 
may  misplace  the  uterus,  and  if  it '  mobile  may  even  impart  an  al)ii 
mal  shape  to  it.  As  a  whole  tne  uterus  may  be  misplaced  forwa 
backward,  to  the  side,  upward,  downward  (prolapse),  or  it  may  be  turr 
inside  out  (inversion).  Again,  the  same  agents  may  bring  about  ^li 
pressure  that  there  is  an  alteration  in  the  direction  of  the  axes  ot  1 
uterus;  it  may  be  rotated  in  its  transverse  axis  (version),  usually  liac 
ward  (retroversion).  This  may  exist  in  all  degrees  from  a  slight  tilt  td  tl 
in  which  the  uterus  lies  with  the  fundus  below  the  promontory  of  t 


THE  UTERI- S 


645 


>a.r,im  and  the  cervix  fH-hind  the  symi)hysis  p.il.is;  these  dishx-ations 
iM.nllv  result  from  childbirth  or  alM)rti()n.  when-  the  iiKrease«l  weight 
ol  thr  uterus  is  not  comiM'iisated  hy  the  fixity  of  its  supjjorts.  Weaken- 
in;,'  ..t  the  round  iiRaments  and,  above  all.  the  lack  of  iH-ririeal  support 
Mlicr  tears,  are  the  most  |)otent  causes.  A  uterus  so  misplaced  is  prone 
tn  impairment  of  circulation  and  may  Ih'coii,  •  coiiKested  and  enlarged 
"I.  I  the  pr.Mluction  of  emh.metritis.  Abnormal  anteversi,,,,  is  not  so 
liiil.le  to  hapiM'u,  and  when  it  dws,  is  usually  from  the  iraction  of  repaired 
ti»iit'  in  front. 

Inver8ion.-"In\  ersion  or  the  uterus  occurs  in  a  large  lax  uterus,  such 
a>  may  be  seen  after  <leli%ery.  It  may  be  (1)  incomplete,  with  the 
tuM,  us  still  within  the  uterus,  or  (2)  complete,  where  the  fundus  lies 
ill  the  vagina,  or  (3)  complet,  with  prolapse,  where  the  uterus  is  wholly 
an.l  tlie  vagina  partly  everte.1.  and  the  uterus  appears  outside  the  vulva 
«lurc  interference  with  its  cir.  illation  may  lead  to  all  degrees  of  degene- 
rati\('  Change,  even  gangrene. 

ProlapM.— In  simple  prolapse,  the  uterus  descends  and  presents  itself 
« itli. .ut  inversion.  It  may  lie  in  the  vagina  (pnH-ide,iiia)  or  with  inver- 
Moii  iA  the  vagina,  may  pro.rude  through  the  vulvar  orifice 

.Nveral  conditions  may  favor  prolapse,  chief  of  which  is  lack  of  sup- 
port, whether  from  weakening  of  the  ligaments  or  of  the  pelvic  floor 
H.troversion  practically  always  precedes  prolapse,  and  is  a.ssisted  by 
injury  to  the  pelvic  floor,  inc-reased  weight  of  the  uterus,  and  laxitv  of 
1 1.  alKlommal  wa  1.  The  bladder  or  rectum  or  both  may  accompanv 
1 1.  t.rus  in  Its  descent.  As  in  retroversion,  but  to  a  greater  degre^ 
tlurc  IS  interference  with  the  circulation  resulting  in  passive  congestion 
aiMl  eiKlometritis.  Prolapse  is  necessarily  accompanie*!  bv  some  dis- 
Iilatriiu'iit  of  the  rectum  or  bladder  or  both. 

Elevation.  -Elevation  of  the  uterus  happens  when  it  is  pushed  up 
r.,j.  l,c|,nv  by  a  tumor.  When  it  gains  attachment  to  the  abdominal 
«a  I.  so  that  involution  cannot  properly  be  accomplished,  the  result 
\Mii  i)rohably  be  an  elongation  of  the  organ. 

nejdon.— For  long  it  has  been  the  custom  to  speak  of  a  lass  of 
abnonnal  conditions-flexions-in  which  the  uterus  becomes  bent 
"P'm  Itself,  guing  anteflexion,  retroflexion,  and  lateral  flexion,  but  at 
PHM  nt  the  tendency  is  to  minimize  the  importance  of  this  change 
•'"'1  ">  merge  each  of  these  in  the  more  important  ter/iio?!  in  the  same 
liirciM,,,.  Retroflexion  is  the  most  common,  associated,  as  it  usually 
»■  uii  1  retroversion,  and  if  pregnancy  occur  the  organ  mav  be  incar- 
^•■nit.cl  in  Its  nev  position,  with  abortion  j.  a  result.  The  causes  of 
n«Mn,„  are  laxity  of  its  tissue  or  its  suppous  and  undue  tractions 
or  prosure    n  one  or  another  part  of  it. 

armrfT^^"-'  ^^'^  already  referred    to   congenital   stenosis:   the 
aqni.d  stenoses  are  usually  due  to  contraction  after  curetting,  or 
'"""  Miatioi,  or  obstruction  of  the  channel  by  tumors.     It  may  tK-cur 
-Nancy  as  a  result  of  gonorrhd'a. 


iiiHai 
in 


)n 


^F^ 


040 


THE  UKi'mnxi  rivK  system 


a ; 


DilkUtion.  Anything  that  favors  retention  Iea«ls  to  distension  of 
the  uterine  <u\ it\  with  vr  without  a  correspondinjf  hypertrophy  of  tlie 
uterine  wall.  As  noted  more  tiian  once  pre\  ionsly,  the  extent  of  this 
hyiwrtrophy  is  largely  a  matter  of  av'e.  In  the  elderly  there  is  little 
reactive  overgrowth  following  the  stress  of  distension.  A  very  frequent 
cause  of  this  is  tl  e  continued  >;rowth  of  an  intra-uterine  fibroniyonia 
which  encroaches  upon  the  cavity.  In  such  cases  the  hyijertrophy  of 
the  uterine  wall  may  he  remarkable.  With  im|)erforate  hymen  or 
cervical  stenosis,  there  may  he  great  distension  from  accumulation  of 
menstrual  fluid  (hematometra).  Retention  occurring  after  the  meno- 
pause or  before  puberty  may  result  in  the  accumulation  of  clear  fluid 
in  the  cavity  (hydrometra).  If  the  obstructed  uterus  become  the  seat 
of  purulent  inflammation,  pyometra  results.  An  infrcfiucnt  condition 
is  thf  accuinulation  of  gas  in  the  uterine  cavity,  .seen  occasionally  in 
the  piierperium  when  putrefaction  of  the  r.f,iiiied  lochia  or  placenta 
is  present. 

Rupture.-  laceration  of  the  cervi.x  is  a  common  event  in  delivery, 
particularly  in  the  primipara.  The  severer  condition  of  rupture  of  the 
body  of  the  organ  may  l«e  brought  about  by  any  condition  which  leads 
to  continued,  strong  uterine  contractions  without  progression  of  labor, 
such  as  occurs  where  there  is  a  transverse  presentation.  Here  one  may 
expect  a  longitudinal  tearing  of  the  uterine  wall,  slight  or  complete, 
with  passage  of  the  foetus  into  the  peritoneal  cavity.  Apart  from  the 
longitudinal,  tears  of  all  jiositioiis  ai'.d  degrees  have  been  observed. 
Previous  disease,  with  degeneration  of  the  uterine  wall,  predisposes 
to  these  events. 

Bruising  and  Perforation.-These  occur  in  attempts  at  mechanical 
abortion,  or  during  operative  measures  (curetting) ;  dilatation  by  force 
is  always  a  crushing  or  bruising.  I:  must  be  remembered  by  the  o\wt- 
ator  every  time  he  takes  a  curette  in  hand  that  the  most  skilful  of 
operators  have  perforated  the  uterus  by  the  use  of  a  force  that  could 
not  be  called  other  than  gentle.  In  these  cases,  the  perforation  is  usually 
at  the  fundus.  Apart  from  these  operative  perforations,  there  may  be 
perforation  resulting  from  cancerous  and  other  deep  ulcers,  these  often 
leading  to  the  formation  of  utero-re'tal,  utero-vaginal  and  utero-vesica! 
fistuljB. 

Circulatory  Disturbances.  —  Hyperemia.  ~  Active  hyperemia  occurs 
physiologically  every  month  during  the  ]h  liod  of  sexual  maturity  of 
the  unimpregnated  female.  Each  menstrual  period  is  immediately 
preceded  by  a  phase  of  active  congestion  of  the  organ  culminating  in 
multiple  hemorrhages  in  the  hypertrophied  mucosa,  and  casting  otf  of 
the  degenerated  mu.osal  cells.  Under  pathological  conditions,  active 
liMieremia  is  found  both  where  there  is  a  local  acute  inflammation 
and  as  an  accompaniment  of  general  infections. 

Hemorrhage. — Apart  from  menstrual  hemorrhage  of  normal  amount, 
there  may  be  menorrhagia,  an  excessive  loss  of  blood  at  the  menstrual 
period.     This  may  be  brought  ;;!>i)Ut  as  a  result  of  chronic  pa:  jive 


HMX)MKrHITl!i 


fy\' 


....Ktstion.  pre|h»,«,He«l  to  hy  tl.o  existeiic'  of  ut.riiic  tumors.  Inith 
Im  niK'ii  and  mnliKiiunt.  as  wvll  as  l,y  tin-  proMiic..  of  iiiHarninati-.i,  of 
till-  uterus  or  its  apjMTulaKrs.     MstrorrbaKia  is  the  esca|)e  fn   .1  the 
iit.rus  of  I.IchhI  whicli  is  not   menstrual.     This  assumes  its  gravest 
ihaKuostic  imi)ort  m  women  who  have  passed  the  menopause,  in  whom 
it>  existence  demands  the  suspieiou  of  the  presence  of  carcinoma  of 
the  uterus.     Apart  from  this,  it  may  <iccur  as  an  accompaniment  of 
u-nu-ra   diseased  states  such  as  the  heniorrliawic  diseases,  and  severe 
irrieral  to.xemias;  more  frequently  it  depends  up.n  some  local  dis<.r.ier 
which  tends  to  congestion  or  ul(^•ration  (endometritis,  new  growth? 
etc.).    Hemonhage,  not  include.!  in  the  alx.ve.  occurs  during  and  afte 
l.arfurition,  in  which   cases  an  excessive  amount   depends  general 
u|M.n  nniK-rfect  contraction  of  the  uterus,  due  either  to  an  inherent 
liHlure  of  the  muscle  to  perform  its  function  or  to  the  presence  of  retained 
plac-nta  or  tumor  which  constitutes  a  i.livsical  obstacle  to  complete 
(...itraction.     In  elderly  women,  associated  vvth  pronounced  arterio- 
>rl,T..tic  changes  in  the  vessels  .,f  :   -,  organs.  ,-  ..,  „,>t  very  uncommon 
tu  have  hemorrhage  of  a  moder.      gra.lc  ii.    'c  mucosa,  with  some 
•  Mai.c  of  blood  into  and  out  of  the  uterine  ca-.itv. 

Inflamm»tion.  — Inaammatiou  may  affect  the  s.rous  covering  of 
thr  uterus  and  the  structures  intimately  connected  with  it  (peri- 
metntis  a  local  i)eritonitis),  the  surrounding  j^dvic  ..rgans,  including 
the  hroad  ligaments  (parametritis),  the  uterine  muscle  (metritis)  or  the 
"Hliiiiictriuin  (endometritis). 

Endometritis.     .Vccording  to  the  region  aft'ectc<l.  so  do  we  sjH'ak  of 
cervical  endometritis  or  cervicitis,  corporeal  endometriiis  of  the  bodv 
<ir  general  endometritis,  involving  the  entire  uterine  lining.    The  same 
;'rM|l.s  ot  inflammation  ma\   occur  here  as  are  found  in  c<  unection 
uith  any  mucous  membrane,  although  the  warning  must  be  given  that 
\.ry  ((.nsidcrable  exnerience  is  requisite  before  the  histological  appear 
aiK rs  .)!  the  endometrium  in  certain  stages  of  the  menstrual  cycle  Ci.-< 
K'  >urc!y  differentiated  from  those  of  iiiHammation.     We  recogniz^ 
tor  example,  acute  catarrhal  endometritis,  showing  hyj  •■•■  nia  With 
'iiM  hargc  of  an  abundant  viscid  or  in  more  advanced  ca.       a  rauco- 
jMinil.Mt  secretion;  this  latter  constitutes  leucorrhea,  of  which  it  mav 
!'«■  NH.i  tiiat,  in  the  majority  of  cases,  it  is  the  cervix  which  is  involve<l 
and  that  we  deal  with  a  recurrent,  often  chronic  catarrh.    More  acute 
ilMurhance   leads  to   hemorrhagic   endometritis.      Acute   endometritis 
.iriM>  from  vaginal  intection,  not  necessarily  gonorrheal;  more  rarelv 
It  H  Ht  dcscen.ling  origin,  and  a  degree  of  it  may  accompanv  a  variety 
'■t  'l^tiirl)ances  of  the  adne.xa,  or  of  the  uterus  itself,  especially  if  these 
iirr  .Krunipanied  by  a  chronic  congestion  of  the  mucosa. 

Chronic  Endometritis.-This  results  most  often  from  a  combined 
'•".'[Thai  disturbance,  and  as  in  the  stomach,  for  example,  so  here. 
'jn  lie  one  hand,  there  may  be  a  distinctly  productive  or  hyperplast  .• 
t"iNliti,.n,  sometimes  even  going  on  to  the  formation  of  nodular,  polv- 
i"  -.   T  iJapiilule  osergrowths  of  the  mucosa;  or,  on  the  other  hand, 


(;48 


TIIK  liEl'UODVCTIVK  SYSTEM 


-t;l 


if  tho  mucous  nieinhrane  becomes  exhausted,  to  atrophy  with  thinnin; 
of  the  eiuiometrium.  Here,  agaiu,  as  in  the  stomatli,  there  may  occa- 
sionally he  iiiHammatory  obstruction  of  the  duets  witii  cystic  dilatatioi 
of  the  same. 

On  uiicroscoi)ic  examination,  if  the  glands  seem  to  be  the  seat  ol 
the  most  marked  chanj;«',  the  state  is  called  glandular  endometritis 
in  contradistinction  to  interstitial  where  th-  morbid  ciianges  in  tin 
interstitial  tissue  seem  to  i)rnlominate.  Microscopic  determination  ij 
difficult  because  of  the  changes  incident  to  menstruation.  The  gland 
tubules  are  generally  lengthened,  tortuous  a.id  irregularly  dilated  even 
to  the  extent  of  cyst  formation;  the  epithelial  cells  have  lost  their  cilia, 
are  clear,  swollen,  and  mucoid.  Th<>  lumina  of  the  ducts  are  filled  with 
mucus,  leukocytes  and  desquamated  cells,  while  the  interstitial  tissue 
is  i)roliferated.  The  ])resence  of  the  glands  among  the  muscle  bands 
nnist  not  be  mistaken  for  malignancy,  for  it  will  be  remembered  that 
there  is  no  submucosa. 

Late  in  the  disease  the  mucosa  i.iay  become  atrophic,  smooth,  thin, 
pigmented,  and  fibrous.  The  accompanying  fibrosis  is  apt  to  compress 
some  part  of  the  tubules  so  that  they  dilate,  .\nother  result  of  irrita- 
tion is  the  conversion  of  the  mucosa  into  squamous  epithelium;  this 
seems  to  bear  upon  the  occurrence  <(f  scpiamous  carcinoma  in  the  body 
of  the  uterus,  but  it  is  likewise  to  be  renu-mbered  that  islets  of 
squamous  epithelium  have  been  discovered  in  the  decidua,  and  even 
in  the  uteri  of  fo-tuses  and  infants. 

Like  the  other  forms  of  inflammation,  chronic  endcmietritis  arises 
from  various  causes,  a  recapitulation  of  which  w»)uld  be  to  repeat 
what  has  already  l)ccn  said  when  dealing  with  the  acute  form. 

In  chronic  cervical  endometritis  a  freciuent  result  is  the  formation  of 
small  cysts,  which  may  attain  the  size  of  a  pea,  the  so-called  ovula 
Nabothi.  They  ha\c  usually  clear,  viscid  contents.  They  are  really 
retention  cysts,  due  to  erosion  (wherein  the  proliferated  epithelium 
"corks"  the  gland  ducts),  and  are  liable  to  infection,  which  may  lead 
to  abscess  formation.  Microscopically,  the  glands  are  seen  to  l)e 
enlarged,  with  many  cells  converted  into  goblet  cells;  such  cases  are 
readily  mistaken  for  carcinrmia.  As  a  rule  in  this  form  of  endometritis 
there  is  abundant  leucorrlia-a. 

As  a  result  of  injtiries  in  labor,  and  secondary  also  to  such  chronic 
catarrh,  the  cervix  is  api  to  show  a  series  of  disturbances.  The  external 
OS  appears  no  longer  round,  but  transverse,  and  the  extremities  of  this 
transverse  slit  are  so  deep  as  to  constitute  actual  fissures,  whose  edges 
are  red,  often  tumefied,  the  tntire  os  sometimes  appearing  coated. 
The  congested  surfact-  readily  erodes  and  bleeds,  and  may  show  a  variety 
of  secondary  changes,  characteristic  of  progress  or  repair  of  the  lesiim. 
Therefore,  we  may  find  ulcerations,  scars,  cysts,  granulations  of  normal 
extent  or  so  exuberant  as  to  suggest  new  growth,  which  indeed  may 
follow  this  <!ir(>nic  inflammation. 


METRITIS 


fi49 


Metritis.— Metritis  is  most  frt'(|U(Mitly  associated  with  the  puerperal 
>tate,  though  it  may  be  secoinhiry  to  acute  iufectiou  especially  if  asso- 
(iatetl  with  the  trauuia  of  ojjcratiou.  The  uteriue  muscle  takes  on  a 
l)ale  color  and  a  soft,  friahle  consistence;  aecompanyinp;  it  there  may 
111'  acute  hyperemia  of  the  en<lometrium  and  occasional  hemorrhages 
within  the  nnisde  substance,  rarely  actual  abscesses,  although  fre- 
(|iifntly  there  is  thrombosis  and  thrombophlebitis  of  the  uterine  and 
DtluT  pelvic  vessels.  If  the  infection  be  not  extremely  acute,  or  again 
as  a  result  of  long-contiiuied  congestion,  a  chronic  metritis  may  result, 
with  enlargement  and  diffuse  fibrosis  of  the  myometrium. 

Perimetritis  is  i)ut  a  form  of  localized  peritonitis  originating  often 
ill  ciinnection  with  inflammation  of  the  adnexa  or  as  an  extension  from 
acute  metritis. 

Tuberculosis.—  Tuberculosis  involves  the  bcnly  of  the  uterus,  rarely 
tlif  cervix  and  vagina;  most  often  it  is  secondary  to  tuberculosis  of 
tlif  tube.  Frequently  the  disturbance  is  not  very  characteristic; 
>iiiall-celled  infiltration,  not  grouped  into  definite  tubercles,  may  show 
liiTc  and  there  an  occasional  giant  cell,  but  only  upon  special  staining 
fur  liacilli  is  the  nature  of  the  condition  surely  recognized.  Occasionally, 
lidwcver,  large  caseous  tubercles  are  encountered,  undergoing  ulcera- 
tion, and  the  process  extends  slowly  but  definitely  into  the  myometrium. 

Syphilis. — There  has  been  much  debate  as  to  the  extent  to  which 
tlic  uterus  is  involved  in  syphilis.  The  jjriniary  sore  may  at  times 
li(  ilctected  either  in  the  vagina  or  in  the  cervix  or  in  its  canal,  but 
aiiparently  infection  may  occur  through  the  uterus  without  there  being 
any  recognizable  primary  sore.  We  refer  particularly  to  those  cases  in 
wliii  h  tiie  child  is  born  syphilitic,  and  the  mother  j)resents  no  primary 
or  <  veil  secondary  lesions,  and  yet  the  prcsetice  of  the  Wasserniann 
niirtion  and  the  fact  that  the  mother  cannot  be  infected  from  the 
infant,  as  also  the  further  fact  that  such  a  woman  may  give  birth  to  a 
M  rics  of  syphilitic  infants,  all  indicate  that  she  is  infected. 

Parasites. Only  rarely  are  echinococcus  cysts  foimd  growing  within 
till  uterine  wall. 

Foreign  Bodies.  -As  in  the  \agina,  so  here,  foreign  bodies  may  lie 
found,  necessarily  less  frequently.  Attention  must  be  called  t»)  the 
111' t  that  i)ortions  of  the  placenta  may  remain  attached,  acting  to  all 
Mill  iits  and  purposes  as  foreign  bodies,  setting  up  irritation,  and  even 
tiiiiiur  growth. 

Regressive  Tissue  Changes.  Atrophy.  Just  as  the  ovaries  come 
til  an  cud  of  tiieir  function  at  the  climacteric,  so  the  uterus,  being 
tiiiH  tidually  useless,  undergoes  shrinkage  after  the  menopause.  It 
iHriiiies  small,  thin-walled,  pale  in  color,  and  the  cervical  portion 
nun  particularly  becomes  diminished.  In  very  elderly  women,  there 
Is  lUcn  to  be  found  an  accomi)anying  congestion  with  hemorrhages 
"I  'i'<    fundal  endometrium.     This  is  not  to  be  confounded  with  an 


'  >4 
It 


;i( 


Hilcction. 


()■)() 


THE  UKPRODVl'TIVK  SYSTK.U 


: 

: 

Progressive  Tissue  Changes.— Hypertrophy.— Apart  from  the  hyper- 
trophy of  pregnancy,  there  occur  other  hypertrophies,  sucli  as  that 
arising  from  infJamniation  and  from  overwork;  overwork  hypertrophy, 
such  as  ib  seen  when  a  large  fibroid  Hes  in  the  cavity,  is  hkely  to  involve 
the  muscle  most,  whereas  that  from  infianmiation  need  not  do  so.  The 
formation  of  polyps,  glandular  hypertrophy,  and  even  the  formation 
of  a  decidua  in  extra-uterine  pregnancy  are  all  examples  of  localized 
hypertrophy. 

Tumors. — These  are  of  great  variety  and  of  nmch  i)ractical  impor- 
tance. The  chief  benign  tumors  are  the  myoma  and  fibromyoma,  lipoma, 
adenoma,  and  so-called  adenomyoma. 

The  most  common  tumor  of  the  uterus  is  the  fibromyoma,  the  so- 
called  fibroid. 

Study  of  the  smallest  and  earliest  of  these  affords  examples  of  pure 
myomas,  of  a  reddish  color,  vascular  ai'd  moderately  soft.  Tumors 
of  a  larger  size  exhibit  a  combination  of  well-formed  bands  of  uii- 
striated  muscle  fibres  alternating  with  baiuis  of  connective  tissue, 
although  careful  examinati(»n  indicates  that  much  of  this  apparent 
connective  tissue  is  formed  of  atrophied  muscle  fil)res.  The  largest 
and  oldest  forms  show  great  degeneratit)n  of  the  muscle,  and  are  com- 
posed in  the  main  of  firm  connective  tissue.  These  are  very  dense  and 
of  a  whitish  color.  In  all  forms,  on  section,  the  surface  is  glistening 
and  has  a  watered  silk  apiiearance  owing  to  the  <omi)onent  bands  being 
cut  in  various  directions.  These  tumors  are  generally  multiple  and 
originate  most  often  in  the  jiosterior  wall,  though  with  growth,  they 
may  come  to  be  subserous,  intramural,  or  submucous.  Tumors  of  this 
order  may  even  become  detached  from  the  uterus,  and  grow  within 
the  broad  ligament,  intraligamentous.  Of  these  different  forms,  the 
intramural  fibromas  i"ay  attain  the  greatest  size,  becoming  as  large 
as  an  infant's  head  or  larger.  Subserous  and  submucous  fibroids  tend 
to  become  pedimculated.  and  with  torsion  of  the  pedicle  the  nutrition 
may  be  interfered  with  and  as  a  result  there  may  be  infarction,  necrosis, 
and  gangrene. 

These  tumors  are  peculiarly  liable  to  show  various  forms  of  circula- 
tory and  nutritive  (listurbances.  Some  are  relatively  vascular  from 
passive  congestion;  others  are  oedeniatous,  tiie  lymph  spaces  becoming 
so  nmch  dilated  as  at  times  to  give  rise  to  a  cystic  appearance;  at  other 
times  the  general  oedema  mimics  a  myxomatous  change  (myxomyoma). 
Fatty  degeneration  is  not  uncommon,  occurring  in  scattered  areas, 
and  beyond  this,  there  may  be  indications  of  a  l(K'alized  or  general 
necrosis,  showing  itself  at  times  as  a  hyaline  change  or  as  a  softening 
and  autolysis  with  cyst  formation,  or  not  infrequently,  as  calcification, 
secondary  to  necrosis.  A  renuirkable  form  of  necrosis  is  that  known 
as  acute  '<5d  degeneration,  due  ajjparently  to  sudden  torsion  of  the  tumor 
and  obstruction  of  the  l)lood  supply.  It  appears  to  be  a  form  of  infarct, 
liarely,  apparently  from  metaplasia,  nodes  of  actual  bone  or  cartiiage 
may  develoj)  within  the  tumors. 


VTKRISE  CMiClSOMA 


651 


These  degenerated  fibroids  may  alsc,  hecome  the  seat  of  infection 
with  resultant  suppuration  and  gangrene,  ..«  a  sequel  of  which  sub- 
iri^ous  fibroids  may  undergo  spontaneous  evacuation 

The  above  myomas  and  fibromyomas  are  characterized  by  being 
well  encapsulated  and  distinct  from  the  uterine  musculature  in  general 
Ihere  is  another  form  of  tumor,  however,  in  which  the  myomatous 
overgrowth  is  diffuse  and  not  encapsulated,  involving  often  a  large 
area  of  the  uterine  wall  and  characterized  by  the  inclusion  of  glandular 
acnn.  lined  by  columnar  epithelium.  It  has  now  been  proved  absolutely 
.A  Cullen  and  others  that  these  gl^uuls  are  extensions  of  the  uterine 
mucosal  glands  deep  mto  the  modiiu>d  myometrium.  This  has  been 
confirmed  by  finding  changes  in  these  glands  at  the  menstrual  period 
nientical  with  those  seen  in  the  uterine  mucosa.  These  glands  show 
no  sign  of  active  independent  growth;  we  deal  not  with  adenomyomas 
l.ut  with  a  condition  of  myomatosis  with  jrlandular  inclusion.  The  name 
a.linomyoma,  however,  has  taken  such  hold  that  it  is  difficult  to 
rt'pliicc  it. 

These  myomas  may  undergo  conversion  into  more  malignant  sarco- 
...atous  growths.  So,  also,  there  are  not  a  few  cases  on  record  in  whS 
the  mucosa  over  a  submucous  fibroid  has  taken  on  carcinomatous 
Rrowth,  infiltrating  the  fibroid.  rLinomatous 

Adenoma    and    Carcinoma.-Polypoid    overgrowth    of   the    mucous 

.mnibrane  IS  not  very  uncommon;  so  also  there  may  be  such  a  localized 

o\  .rgrowth  of  abundant  uterine  glands  that  it  is  difficult  to  say  whether 

^^e  deal  with  an  inflammatory  or  a  neoplastic  process.    Nevertheless 

at  tunes,  this  adenomatous  infiltration  of  the  muscular  wall  may  be 

.^>  (xcossive  that  there  can  be  no  hesitation  in  speaking  of  this  as  a 

mabgnant  adenoma,  more  particularly  as  secondary  growths  of  adeno- 

iiiatous  type  may  appear  in  the  pelvic  lymph  nodes.    This  is  one  tvpe 

o   uterine  carcinoma.    Allied  to  this  is  the  adenocarcinoma  found  in 

h..  cervical  canal,  and  occasionally  in  the  body.     Here  in  place  of 

.N pi.al  there  is  atypical  .levelopment  of  the  glandular  elements     This 

.'nn  appears  to  originate  most  frequently  from  the  occluded  glands 

muh«  Nabothi.    This,  like  the  former,  infiltrates  extensivefy^  the 

I  soIIh'  """""^  r^T-*"/  ^'°''*''?'  ^^  ^^'^t"'"  *'>^  P"'-^  carcinoma, 

«itl  sol  d  u  ii  masses.    Colloid  cancer  is  distinctly  rare. 

I  Ins  forms  one  group  of  uterine  cancers;  the  other,  and  smaller 

^oup  originate  m  connection  with  the  squamous  epithelium  of  the 

<'r\i.v,  only  a  few  cases  having  been  recorded   developing  from  the 

.■n  .nd  canal  or  the  body  of  the  uterus.    This,  the  squaiouf  carcLma 

1  "  ,!  ^^*'  "!'*''  "\''  somewhat  superficial  growth,  at  times  tending 

K    papillomatous,  having  a  distinct  tendency  to  ulceration  and 

n.-ion  with  progressive  invasion  of  the  deeper  tissues.    It  may  extend 

;.  up  the  cervical  canal  into  the  body  of  the  uterus,  SsSy 

iiiii.i rate  the  neighboring  oreans.  ^ 

m  the  above  description  it  will  be  seen  that  carcinoma  involves 


all 


'  'rt>  o»  the  womb,  but  the  cervix  most  frequently.    Uterine  cancer 


G.j2 


rilE  REI'RODVCTIVE  SYSTEM 


is  one  of  the  commonest  of  all  forms  of  malignunt  jrrowth  and  of  carci- 
noma in  the  female,  one  out  of  every  three  cases  is  uterine.  In  the 
nuUiparous,  the  condition  is  rare,  and  then  most  frecjuentiy  affect- 
the  corpus,  whereas  in  the  woman  who  has  l)orne  children,  the  cer\ix 
is  the  part  most  often  involved.  This  leads  us  to  see  some  relationship 
between  trauma  and  scarring  f  the  cervix,  and  subsequent  cancerous 
de\elopment.  Cancer  develops  most  often  after  the  menopause,  and 
we  can  but  rcj)cat  the  warning  that  a  hemorrhage  from  the  womb 
developing  after  the  cessation  of  menstruation  demands  careful  examina- 
tion for  the  presence  of  a  carcinoma. 

Sarcoma. — Sarcoma  is  distinctly  less  frequent  than  carcinoma, 
is  apt  to  arise  at  an  eailicr  life  periotl,  and  most  frequently  affects 
the  body  of  the  organ.  The  gr{)wths  are  pale,  nodular,  often  multiple 
with  extensive  infiltration  of  surrounding  tissues.  EndotheUomas  are 
still  less  common. 

Cysts. — We  have  already  referred  to  the  ovula  Xabothi  and  other 
retention  cysts  of  the  uterine  glands,  as  well  as  to  the  necrotic  and 
angiectatic  cysts  of  uterine  fibroids.  Teratomatous  cysts  have  been 
recorded. 

THE   FALLOPIAN   TUBES 


The  Fallopian  tubes  may  vary  considerrbly  in  their  position  accord- 
ing to  the  relationship  of  uterus  and  ovakies.  Their  freedom  of  move- 
ment permits  them  to  be  included  in  any  conglutination  of  pelvic 
surfaces  and  organs,  and  as  a  result  they  are  distinctly  apt  to  exhibit 
infiamniatory  an<l  other  disturbances.  Again,  their  function  as  carriers 
between  o\ary  and  uterus  permits  them  to  become  the  site  of  gestation 
— tubal  gestation.  What  is  the  cause  of  this  is  still  a  matter  of  ilebate. 
It  is  natural  to  imagine  that  slight  bridges  and  infiamraatory  scarring 
of  the  mucosa  of  the  tube  by  arresting  the  outward  passage  of  the 
ovum  favors  its  arrest  in  the  course  of  the  tube,  but  when  we  come 
to  attribute  tiie  condition  to  gonorrheal  or  other  salpingitis,  the  great 
frequency  of  the  condition  in  some  rcgi(»ns,  as  in  certain  parts  of  Western 
Pennsylvania,  is  wholly  out  of  jjroportion  to  the  incidence  of  infection 
and  the  exact  causation  remains  unexplained.  Such  ectopic  gestation 
occurs,  but  with  great  rarity,  in  the  ovary  itself.  Much  more  commonly 
it  shows  itself  in  the  course  of  the  tube,  5>ither  toward  the  distal  end, 
or  in  the  central  region  or  somewhat  rarely  in  the  uttrine  portion  of 
the  tube  (interstitial).  As  a  result,  with  the  reaction  on  the  part  of  the 
mucosa  of  the  tube  to  form  a  decidua  there  is  an  extraordinary  conges- 
tion of  the  blood  vessels  of  the  tu'oc  and  as  the  gestation  sac  increases 
in  size  the  walls  of  the  tube  become  so  much  thinned  that  rupture  may 
occur  with  escape  of  the  fa'tus  into  the  peritoneal  cavity  or  the  broad 
ligament  and  associated  profuse  hemorrhage.  In  this  new  position  the 
foetus  may  gain  a  new  placental  attachment,  and  rare  cases  are  on  record, 
in  which  the  foetus  has  developed  to  full  term.    Much  more  frequently 


rut:  FALI.OPIA  .    TUBES 


Cm:? 


t  .«■  uiirontrollf*!  lieinorrhaKe  leads  to  a  fatal  issue,  or  where  the  hemor- 
rliajie  is  not  so  extreme,  the  foetus  dies  and  heeomes  a  lithopedion. 
I  liese  eventuahties  (K-eur,  of  eourse.  in  the  ahsenee  of  surgical  inter- 
vention. It  is  interesting  to  observe  that  a  sympathetic  decidual 
lormation  or  change  in  the  mucosa  may  sIk.w  itself  in  the  op.K)site 
tiilie  or  m  the  uterus. 

Congenital  Abnormalities.  The  commonest  congenital  abnormality, 
s(.  common  as  to  be  practically  normal,  is  the  pi  >sencc  of  the  hydatid 
of  Morgagni,  a  cystic  dilatation  and  enlargement  of  the  longest  of  the 
fiml)rue.  This  is  present  in  more  than  20  per  cent,  of  autopsies  upon 
tlic  temale.  I^ss  commonly,  variations  are  seen  in  the  distal  end 
Ihere  may,  for  example,  be  a  double  orifice  with  a  separate  collection 
..t  tiinbria-  around  each,  and  very  rarely  the  tube  itself  shows  some 
(iui)iication.  Diverticula  are  sometimes  noted.  There  may  be  complete 
absence  of  one  or  both  tubes,  generally  associat.d  with  al)sence  or 
iniiltormaticm  of  the  uterus. 

Circulatory  Disturbances.— These  call  for  no  special  remark,  in 
inflammatory  states,  there  is  acite  hyperemia,  at  times  with  associated 
hemorrhage.  The  condition  of  hematosalpinx  or  accumulation  of  blood 
111  tlie  tube  IS  occasionally  encountered  by  regurgitation  of  retained 
menstrual  blood,  or,  some  hold,  from  actual  hemorrhage  in  the  tube 
(luring  menstruation. 

Inflanunation.— The  more  accurately  the  bacteriolog\-  of  the  inflamed 
till).-  is  studied,  the  more  il  is  seen  that  gonorrhea  is  the  commonest 
•  Muse  of  acute  or  subacute  salpingitis.  There  may,  it  is  true,  be  infec- 
tioM  by  the  strejrto-  and  staphylococcus,  but  these  are  not  so  frequent. 
I  hi'  results  are  a  swelling  of  the  mucosa  with  pronounced  purulent 
M  ( rction  which  in  cases  of  obstruction  of  the  tube  pass  on  to  its  grc-.t 
(!i;t.nsi(,n  with  actual  pus  (pyosalpinx).  A  marked  characteristic 
n  -unorrheal  salpingitis  is  that  while  the  lumen  of  the  tube  mav  be 
hll.MJ  with  ordinary  pus  cells,  coincidently  the  greatly  infiltratecrsub- 
niiHosa  may  show  an  extreme  accumulation  of  plasma  cells  Recen'^ 
auilK.rities  hold  that  this  abundance  of  plasma  cells  is  i-athognomonie 
"t  L'Mn„rrhea!  infection.  With  this  infiltration  of  the  submucosa, 
tlir  Muicoiis  membrane  shows  pronounced  loss  of  epithelium  and  the 
riiUM'  iire  flattened,  so  that  the  mucosa  becomes  less  iiifolde-i  This 
v<r>  .lestruction  of  the  mucosji  favors  the  subsequent  formation  of 
iTH  ires  and  bands  of  connective  tissue  with  stenosis.  It  is  characteristic 
"t  "Ins  acute  inflammation  of  the  tube,  that  the  ends  are  apt  to  become 
Mill.,!;  and  even  while  at  first  this  sealing  be  through  swelling  of  the 
i"'j'  osj,  and  the  viscid  nature  of  the  secretion,  it  is  apt  to  be  ultimatelv 
l<ili"«(d  by  organized  obliteration,  with  consequent  sterilitv  \ 
St"  n< I  point  IS  that  with  this  sealing  and  subsc(,uent  distension  of  the 
till" .  the  fimbria'  are  apt  to  become  inverted  with  complete  disappear- 
"II-  .  a  third,  that  despite  the  great  distension,  the  tube  adapts  itself 
iiml  rupture  rarely  occurs. 

'""•rding  to  the  grade  of  inflammation,  we  obtain  conditions  of 


11 


¥^!f■^^s 


().-)4 


rHK  REPKODVCriVE  SYSTEM 


11 


hydrosalpinx  and  pyosalpinx.  Pyosalpinx  is  tlic  result  of  a  contiii 
supj)urati\('  iiitVctioii.  Hydrosalpinx  occurs  whtro  there  has  bee 
previous  iuflainination  that  has  sealed  up  the  tube  and  then  came  t( 
end,  and  is  the  exjjression  of  the  continued  secretion  from  the  muc 
of  its  normal  i)r<Mluct,  a  nnicoid  Hiiifl. 

As  with  the  appendix,  so  here,  inflammation  involving  primarily 
mucosa  is  liable  to  spread  through  the  walls  and  induce  a  perisalping 
which  in  acute  cases  may  be  suppurative,  leading  to  an  acute  pe 
peritimitis.     More  frequently  this  assumes  the  form  of  an  adhe; 
inflammation  with  extensive  adhesions  so  that  the  tubes  aiid  all 
pelvic  contents  are  densely  bound  together. 

Specific  Infections.-  Next  in  fncpiencx  i»  gonorrheal  is  tubereul 
salj)ingitis.  While  this  may  be  of  hematogenic  origin,  it  appears 
(piently  to  be  induced  by  bacilli  carried  down  the  tulie  in  the  peritoi 
fluid,  from  the  ovaries  or  other  abdominal  organs,  or  upward  from 
uterus  and  vagina.  In  the  early  stages  the  changes  are  not  charaeteris 
there  is  a  small-celled  infiltration  of  the  mucosa  and  submucosa  v 
generalized  thickening  of  the  tube.  Later,  tubercles  with  ease 
centres  are  to  be  made  out,  and  the  whole  interior  of  the  tube  may  si 
extensive  fused  tubercle?  with  advanced  caseation,  which  with  sten 
of  the  ends  of  the  tube  may  lead  to  a  condition  simulating  pyosalp 
the  greatly  disteiided  tube  filled  with  soft,  cheesy,  or  thick  purifc 
matter  (tuberculous  pyosalpinx).  Here  again  the  tuberculosis  pro( 
is  liable  to  extend  outward  involving  the  serosa  and  leading  to  tube 
formation  w  ith  adhesions. 

Syphilis.-  Contrary  to  expectation  syphilitic  lesions  in  the  Fallof 
tubes  are  distinctly  rare.  Gummas  have  been  recorded.  So  also  tl 
are  a  few  cases  of  actinomycotic  lesions,  due  to  a  secondary  and  desct 
ing  infection. 

Progressive  Changes.-  Productive  inflammation  may  show  it 
as  a  distinct  overgrowth  of  the  mucosal  folds,  and  with  the  abund 
infolding  of  the  mucosa  the  enlarged  tube  may  on  section  be  mista 
for  an  adenomatous  development  composed  of  abundant  brand 
glanduhir  acini  lined  by  columnr  ejiithelium.  Primary  tumors 
infrequent;  papillomas  and  carcinomta  are  encountered,  and  a  few  ci 
of  myoma,  fibroma,  and  lipoma  are  on  record. 


THE  OVARIES 

The  average  adult  ovary  may  be  said  to  be  somewhat  of  the  : 
and  shape  of  the  first  phalanx  of  tlie  adult  male  thumb.  The  ov 
is  developed  from  the  Wolffian  body  by  the  ingrowth  of  the  germi 
epithelium.  It  is  from  these  ingrowths  that  the  Graafian  follicles,  w 
their  contained  ova,  are  developed.  The  stroma,  on  the  other  \\;iw 
of  coiinectix  e-tissne  origin.  The  ovary  is  thus  entirely  mesoblastic, : 
tumors  arising  from  it,  even  if  histologically  of  carcinomatous  tyju', 
mesothelial  (mesotheliomas),  or  mesenchymatous. 


77/ A'  OVMilKS 


Abnormalities.-  One  or  hotli  ovaries  may  he  wanting,  and  this  usually 
MicdinpaMies  other  grave  defer  ts  of  the  fienito-iirinary  system.  There 
iiiiiN  liiv-ewise  he  hypoplasia  of  one  or  both,  with  a  relative  absence  of 
(iniafian  follicles.  So  also  oeeasionally  accessory  ovaries  have  been 
fiir  entered.  Of  abnormalities  of  position  the  most  important  con- 
pi  uial  condition  is  descent  of  the  o\ary  into  the  canal  of  Nuck,  simu- 
IntiiiR  the  descent  of  the  testis  into  the  inRuiiidl  canal. 

Circulatory  Disturbances.  -It  is  notable  that  active  hyperemia  of  the 
(iviiry  may  be  extreme  in  the  menstrual  period,  leading*  to  such  dilata- 
tion of  the  arceries  that,  as  in  t!ie  uterus  after  pregnancy,  there  mav  be 
ii  siibsequep+  reduction  in  size  of  the  vessels  by  means  of  new  growth 
of  the  intinici  tissues.  The  vessels  similarly  may  show  passive  hyper- 
emia in  obstructive  cardiac  disease  or  from  torsionor  other  local  obstruc- 
tion to  the  venous  outflow.  Physiological  hemorrhage  occurs  into  the 
niri)()ra  lutea,  and  pathological  hemorrhage,  generally  localized,  is  found 
in  various  acute  infections. 

Inflammation.— Oophoritis.-  In  all  cases  of  acute  peritonitis  the  ovarv 
i>  t'oinid  reddened  and  congested:  it  may  even  i)e  infected  in  general 
Imctcriemia;  but  by  far  the  most  frequent  causes  of  inflammation  lie  in 
tlic  spread  of  infection  from  connected  structures,  especially  the  tube, 
iind  this  notably  from  gonorrliceal  virus.  The  inflammation  so  set  up 
niiiy  he  diffuse  or  follicular,  and  as  a  result,  the  ovary  mav  be  soft, 
•iiliirKcd,  and  cedematous,  or  suppuration  in  small  or  large  areas  be 
xrii.  The  entire  organ  may  be  converted  into  a  sac  of  pus,  which  mav 
rupture:  such  a  change  is  usually  accompanied  by  fixation  to  the  tube 
iiMil  otiier  nearby  structures,  so  that  a  mass  of  inflammatorv  mate-ial 
i>  loiind  in  which  it  is  recognized  that  both  ov-ry  and  tube  have  par- 
ti(  ipated.  This  is  known  clinically  as  a  tubo-ovaiian  abscess,  and  may 
iirbc  ((pially  from  either  constituent. 

A  trc(|uent  result  of  oophoritis  is  that  j)elvic  adhesions  result,  and  the 
iiifiimicd  ovary  is  often  fotind  in  Douglas's  pouch.  In  considering  the 
f;<  iirsi.  of  ovarian  abscesses,  it  must  not  be  forgotten  that  the  verv 
ln(|ii.ntly  seen  follicular  cysts  of  the  ovary  may  become  infected. 

Chronic  Oophoritis.— In  this  the  ovaries  are  found  dense,  of  an  ivorv 
<'|l"r.  and  while  they  may  be  smooth,  the  surface  is  usuallv  corrugated, 
"ith  ,,r  without  adhesions.  Warning  must  be  given  that  a  similar 
< M'Timl  aj)pearance  is  seen  in  the  shrunken,  atrophic  ovaries  of  old 
"onu  n.  In  the  younger  adult,  this  thickened  condition  of  the  outer 
l;i><  r  of  the  ovary  is  due  to  an  inflammatory  fibrosis,  and  is  important 
"'  'l.it.  .)l)viousIy,  it  hinders  the  rupture  of  the  follicle  and  the  escape 
"'  '!'<  ovum.  Such  unruptured  follicles  undergo  degeneration  and 
I'"  "in.'  (oiivcrted  into  small  cysts,  which  are  a  characteristic  feature  in 
"^:in.  Y'f  this  order.  The  stroma  in  general  shows  an  increased  fibrous 
"M"  rplasia.  Chronic  inflammation  of  the  ovary  usually  results  from 
;"'"i;!nance  of  an  acute  infection  or  from  recurrent  attacks  of  a  milii 
irrii  iMt.    Tuberculosis  and  syphilis  are  rare  in  the  ovary. 


i\ry(\ 


Till-:   l<KI'l{i>l>l('nVK  SYSTEM 


Kicj.  L'!l."i 


Regressive  Tissue  Changes.    W'v  liavo  aln-ady  rrforri'd  to  tlie  atroii 
and  fihrotic  coiKlition  si-coiidary  to  oiiphoritis.      It  was  tluTe  sta 
that  a  soiiH'wIiat  similar  appfaraiur  is  tiicoiintiTt'd  after  tin-  niei 
pause.     As  a  result  of  ineiistniatioii  hyaline  and  elastoid  elian^es 
s«'en  in  the  arteries. 

Progressive  Tissue  Changes.    Tumors.     If  a  niorpholo^'ieal  elas> 
cation  he   used,  it   is  likely  to  i)e  ineorreet  enil)ryolo>;ieally,  for 
etiology  of  many  of  the  ovarian  growths  is  yet  in  douht. 

It  is  possible  to  ilivide  them  ronjrhly  into  the  eystie,  the  cystic  ii 
solid  mesotlielioniatous  or  carcinomatous  tumors,  the  eonnective-tis: 
growths  and  the  teratomas,  a  division  which  will  serve  to  i)revent  ci 
fusion. 

Cysts.  7  These  are  of  ^'reat  variety,  and  it  may  he  stated  hy  wa\ 
preface  that  they  can  ori>;inate  from  the  follicles,  from  the  gerini 
epithelium,  or  from  Wolffian  "rests." 

1.  ('i/.itir  Diiii'iiirntiitn  of  the  Omry. — This  is  ciuiracterized  hy  i 
appearance  of  numerous  small  cysts  throughout  its  substance,  lined 

a  single  layer  of  ceils,  in  jjlaces  ciliat( 
there  is  no  follicular  ei)ithelium  of  1 
usual  type,  and  no  ovum.  They  ni 
hv  found  in  the  newlxirn.  The  w 
is  constituted  l>y  the  thickened  w 
of  the  follicle,  and  the  fluid  is  cle 
It  seems  likely  that  an  ill-timed  rij)! 
ing  of  a  follicle  is  responsible  for  th 
occurrence. 

'1.  FdlliciildrCj/Kix.-'Vhvi^aKof t 
nature  of  true  retention  cysts.  I'siia 
thtse  cysts  are  multiple  and  sini 
but  occasionally  a  single  larger  c; 
is  f(,.  lid.  When  small  they  are  lin 
by  cylindrical  epithelium  and  at  tin 
a  persistent  ovum  is  seen.  When  lar 
the  epithelium,  through  pressure, 
flattened;  they  contain  a  limpid  flu 
Quite  analogous  to  these  are  the  <  y: 
originating  in  corpora  lutea,  usually 
l)e  known  by  their  thick,  wavy,  liyiili 
wall.  In  these  the  fluid  is  apt  to 
colorcfl  l)y  modified  blood  pigment. 
'A.  Cjistiulcninnd.f  {('iidDiiia.i,  or  (iUmduhtr  P.ieiidounwinou.'i,  Mul 
lanilar  Ci/st.i).  The  alternative  names,  taken  together,  descril)e  t'aii 
accurately  these  cysts,  the  most  conunon  neoplasm  that  is  found 
the  ovary.  'I'hex  are  unilateral  or  often  bilateral.  Xow-a-days  tluy  a 
iisually  removed  by  operation  before  reaching  a  great  size,  but  former 
cases  have  iseen  ilescribed  in  which  the  weight  of  the  cyst  ex<eedi 
that  of  the  patient  after  its  removal.     The  mass  consists  of  one  ina 


Sri'tion  thnniKh  ovary  rxliibitinK  iniiiti 
pic  fi)IIi(-uhir  rj.sts  of  v:ir\iiiK  sizt'  tn.  h,  r 
..iiiul  /);  ./,  Kiillcipiiiii  lull!'.  (McGil 
Path.  -Mus.) 


nVARlAX  CYSTS 


657 


'.\-.t  of  liir^i'  si/e,  with  several  siil).si(liiir\-  or  »laii)rlittT  cysts,  wliich  may 
(•\i-t  iiKlepi'iidt'iitly  in  the  stroma  or  may  oiicroach  upon  the  cuvity 
ot  the  major  cyst.  Oii  the  inner  wall  are  rid^'es  represent  in  jj  former 
.li\i>i()ns  between  the  cysts,  the  larger  cyst  being  developed  from  the 
(i.iilhu-iice  of  smaller  ones.  The  cyst  wall  is  tough,  thin,  and  trans- 
liK  rut,  hnt  in  some  cases  thick,  its  hlood  supply  being  the  large  ves.sels 
tliiit  nunify  on  the  surface.  The  Huid  is  of  varying  consistence,  thinnest 
ill  the  large>t  cyst,  having  a  specific  gravity  between  1010  and  HYAO. 
It  may  be  viscid,  mucinous,  clear,  glassy,  turbid,  brownish,  or  at  times 
I.IimmIv.  B(Mlies  related  closely  to  nuicin  (pseudomucin)  and  albumin 
arc  I  resent  in  the  fluid. 


Multilocuiar  ovarian  cyst. 


I  he  (■>  St  wall  IS  composed  of  two  layers,  the  outer  dense  and  fibrous 
tlic  iiiiMT  cellular  and  vascular.  A  single  layer  of  c^  lindrical,  columnar 
;ylU  null  basally  placed  nuclei  lines  it  internally  (see  Fig.  143,  p.  292). 
i'liH  '  |)itliclium  has  a  pronounced  tendency  to  "form  multiple  papiHa'ry 
iiii;r(,utlis,  and  an  equal  tendency  to  give  origin  to  downgrowths  into 
tiii  r\  .t  wall,  which,  becoming  snared  off,  ilevelop  into  secondary  cysts. 
.Mi(n,M(.pically,  the  lining  cells  arc  distinctly  mucinous,  but  thev  mav 
^li"u  \  ;iri()iis  kmds  and  grades  of  degeneration.  In  addition  to  pseudJ- 
iiiii'in  the  Huid  may  contain  fat  gobules,  leukocytes,  degenerating  cells, 
i'l'""l.  aiul  cholesterni.  The  i)osidon  of  the  cyst  in  relation  to  the  tube 
1^ '  I  .iia.tcnstic.  The  tube  can  be  lifted  off  the  cyst,  except  in  those 
nin  ,,,Ms  Ml  which  the  cyst  develops  between  the  lavers  of  the  broad 
li^-Min^iit. 

\\i  li  the  continued  growth  of  the  cyst,  it  lifts  itself  out  of  the  true 


jii'ili,  i 
dti't'.. 
it>  li 

llt'(T(  ■ 


Hid  elongates  the  ovarian  ligament,  which,  acting  as  a  long 
In  a  relatively  movabi,  growth,  is  liable  to  be  twisted,  shutting 
'  irciilation.  The  cyst  wall  then  becomes  dark  red  in  color,  and 
-ii>  max  show  all  grades  of  hemorrhagic  infarction,  even  to 
■•     A  large  cyst  may  break  and  discharge  its  contents  into  the 


II' 
\l 

'  i 


•I 


i 


058 


THK  uEPRomrrivK  system 


]H>rit(tiictiin,  \vlnT»'  the  mass  t>f  imicinoiis  inatfrial  may  he  walle<l  aniiiiid 
and  form  a  kind  of  falsr  iniiciiious  tiiiiior  (pseudomyxoma  peritonei). 

Papillary  Cystoma  (Cystadenoma  Papilliferum).  A  wt'll-kiiowii  rlinicii 
variety  of  this  onh-r  of  tumor  is  the  so--,"ilk'd  cystadenoma  papillifeniiii 
in  which  the  pai)ilhiry  growth  is  very  pronounced.  The  ca\  ity  m 
cavities  arc  more  or  U'ss  filled  with  warty,  villous  or  tree-like  excres 
fences  formed  of  proliferated  stroma  covered  hy  ciliated  cylindrica 
ei)itheiiuni.    The  stroma  is  fairly  vascular,  hut  may  nnder^o  a  uiucinou: 

Fin   297 


CyBtadenoms.     Multilocular  ovarian  cyst.     (Dudley.) 

(lcj;cncration.  When  the  papilhe  appear,  as  they  sometimes  do,  on  tli 
outside  of  the  cyst,  it  means  that  a  rupture  of  the  cyst  wall  has  occurrod 
permitting  the  i)apillie  inside  t<>  burst  forth;  sometimes  the  pai)illi 
actually  invade  the  cyst  wall.  In  such  a  case  the  cystic  quality  (i 
the  tumor  has  receded  ami  it  approximates  more  than  before  to 
])ai)illoma. 

The  fluid  is  thin  and  watery,  at  times  bloody  in  appearance.  In 
tumor  is  an  important  one,  because  in  time  it  Ix-comes  malij;iiiiii 
(a  quality  foreshadowed  by  its  infiltratini:  its  own  wall),  giviiij:  ris 
to  secon(iary  nodnles  on  tlic  |)eritonenin.  The  orijrin  of  cystadenoma 
has  led  to  mudi  discussion,  and  the  question  is  still  an  open  one.     Lcav 


THE  OVARIES— rUMOHS 


a-)9 


111^'  this  questu.n  nwrssurily  imsettltfl.  then-  is  h  natural  transition  to 
tlu-  carcincrnas,  consi.lrrinjf  tin-  ^mit  lial.ilit.v   for  the  l)cniKn  tinnors 
.-|..-<ially  the  (Vstic  ones,  to  hecon.e  inaliKimnt.     Like  the  cvstmlem.ma' 
("ir.  inonia  of  the  ovary  has  l,een  foun.l  in  earh-  Hfe.  even  hefore  puKerty 

Carcinoma.  ^  These  are  cystic  a»ul  soUd,   tlie  forjner  arising  in  the 

•'•■  ;>'*t|i<'«'''<'"i"s.  or  even  more  fre.,uently,  in  the  papillomatous 

.m.s.  In  the  former,  wliieh  in  p-ni-ral  resemble  their  non-rnalitmant 
|.n.totyiH.s.  the  walls  an<l  septa  are  infiltrated  with  n.nlnles  xvhich  are 
ninsses  of  epithelial  eells.  Multiple  rows  of  eells  replace  mi.kIc  rows- 
tlir  liiiKl  eontents  are  clondy  fn.m  admixture  of  eells  and  hlood  at 
tiiiHs  viscid,  or  even  colloid. 

Ill  the  papillary  tyjR.  (cystadenoma  papilliferum  maUgnum)  the 
Ininkly  malignant  form  of  the  tyi)e  above  des<ribed,  the  i)apilhe  i;row 
.xiilKTantly,  and  the  septa  are  infiltrated  with  impill.,matous  masses 
wIm.1.  may  Kr..w  ri^dit  throiiKh  the  walls  an.l  appear  externallv.  dvini:' 
riM  to  peritoneal  and  broad  ligament  metastases,  and  to  seeondarv 
irrowths  in  distant  orRans.  .\t  times  it  may  be  difheult  to  determine 
wliHher  a  Kiven  earcinoma  is  primary  in  the  stomach  or  the  ovarv 

I  he  solid  careinomas  of  the  ovary  form  smooth  or  laxlular  growths  of 
hrzv  size  and  may  be  unilateral  or  bilateral.  Thev  mav  be  of  nniform 
rniluT  soft  consisteii.e,  and  exnd.-  a  milky  fluid  op  pressure,  or  mav  be 
M  irrh.ms  <)r  even  colloid.  Histologically,  they  mav  be  difluse,  alveolar 
.|r  mny  simulate  tubules  of  cylindrical,  cuboi.lal,  or  polvmorphous  cdls 
All  .d.undant  deix.sit  <.f  calcareous  material  may  give" rise  to  psammo^ 
carcinoma. 

!;il.l.ert  rcRards  these  as  embryomas  in  which  the  entoderm  or  hvpo- 
I'lii^t  alone  has  undergone  development,  and  compares  the  papijlarv 
^ToM  ,  to  .•horiouic  villi.     We  are  not  prepared  to  accept  this  view 

'Mt.  Iron,  the  studies  of  our  colleague  Dr.  Goo.lall,  are  inclined  to 
I"  II'  y«'  that  the  origin  is  from  certain  remarkable  downgrowths  of  the 
i;.ri„mal  ei.ithehum  which  do  not  uiulergo  development  into  (Jraafian 
'"llH  l.>.  I,ut  are  h)und  persisting  in  about  1(»  per  cent,  of  human  ovaries 
III '  H  I'.rm  of  spaces  or  cavities,  lined  by  an  epithelium  which,  according 
"'  111'   iuriod  and  stage  of  development,  is  curiouslv  variable  in  its 
ll^ir;,.  t.Ts.     An   lutcrestmg  feature    about   these  persistent   growths 
1^  ili.t  they  show  a  marke.l  liability  to  the  formation  of  capillarv  iu- 
^rnuil,,,  as  again  to  the  development  of  outgrowths  at  times  solid 
•It  tinirs  glandular  or  cystic,  into  the  surroumling  ovarian  tissue      We 
1|'---  here   in  short    an  organ  or  part  capable  of  giving  origin  to 
"iiiI'M'l'  cysts  and  to  intracystic  ingrowths. 
Connective-tissue  Tumors.-Of  the  connectiN-e-tissue  tumors,  the  most 

'lip    'iMt  are  fibroma,   adenofibroma,   cystoflbroma,  myofibroma,   endo- 
tnelionia,  pentheliomt,  and   sarcoma.     Fibromas   usualh-   form   difluse 


l-llllh 
Ti, 
1 1  Mir; 
tlif\ 


„..i,       .,,         .,  ,  "■■    "■^""■v    ""111    uuiuse 

;\tlis  with  unitorra  enlargement  ot  the  ovarv,  but  ma\-  be  cir- 

nlicd  nodules,  unilateral  or  bilateral. 

sarcomas  are  not  nearly  so  common  as  are  carcinomas  of  the 
I  -Ike  so  many  of  the  ovarian  tumors,  they  tend  to  be  bilateral  • 

-|>  be  round-celled,  spindle-celled,  or  giant-celled,  and  it  has  been 


-'I 


('>('>() 


THE  KKI'Kom criVh    SYSTEM 


siiKKf-^tt'd  tliat  tlu'  last  (iriKiiiatc  iM)s;*il>l\  fnirii  tlic  iiittTstitial  «rlls  wliic 
art-  «)f  lik«'  orijjiii  with  tlif  cells  of  t\\v  (Jraatiaii  folliclrs.  Soiiu-  cast 
are  on  rocunl  of  trm-  e&rclnonui  Bwcomatodu.  Tlu'sf  jHTliaps  repn-sci 
transitional  tvjM-s  sirii  in  tumors  of  tncsotlu-liul  origin. 

EndothellomM  are  ocrasioiuilly  fncountcn-fl,  but,  lu-rr  ajtaiu,  tluTi- 
a  HTViit  lial)ility  to  classify  eoniplicatctl  and  ilouhtful  tumors  of  tl 
transition;!!  type  as  cither  endo- or  iH-rithelioma.     Much  fuller  >tu<i 
is  necosarv  before  we  can  pro|)erly  classify  the  ovarian  new  growtlis. 

Teratomu.  These  constitute  a  class  apart  and  are  not  uncommoi 
They  arc  emhryomas.  or  as  stated  on  p.  2(K»,  the  result  of  aln-rrai 
growth  of  totii)otent  ovarian  germ  cells.  They  are  jififwHy  <>^<i' 
although  solid  forms  con-istiiig  of  cells  (h-rived  from  all  three  gcri 
layt-rs  are  at  times  met. 

Cystic  Teratomas.  .\p|H>arinn  ns  v  vsts  of  any  size  u|)  to  fivi-  or  s 
inches  in  diameter,  usually  solitary,  '.n\t  sometimes  multiple  and  li 
lateral,  these  are  s|)ecially  prone  to  api)ear  after  jtuhcrty.  On  openiii 
the  cysts  are  seci.  to  contain  tallow-like  contents,  mixed  with  liai 
sometimes  the  contents  are  thin  fluid  with  tallowy  masses.  The  hai 
are  fixed  to  skin  reseml)lin>;  the  scalp,  which  covers  a  knohhod  i)art  < 
the  inner  surface,  the  rest  heing  covered  l>y  what  looks  like  mucoi 
memhrane.  rnderlying  the  knob  may  l>e  bone,  and  in  it  are  oftt 
incisor  teeth,  sometimes  in  a  row  as  in  the  jaw.  Microscopic  exaniiii 
tion  through  the  knobbed  porti«»n  shows  hair  follicles,  sebaceous  ai 
sweat  glands,  portions  of  bone  and  cartilage,  sometimes  structures 
the  eye;  in  fact,  almost  any  structure  found  in  the  embryo  may  1 
seen,  aiul  even  ath'mj)ts  at  limbs  have  been  observed. 

Solid  Teratomas.-  The  solid  teratomas  are  less  common.  The  tunn 
on  secticm  shows  mnltii)lc  small  cysts  with  serous,  mucinous,  or  U\\\o\ 
like  contents,  lined  by  ciliated,  columnar  or  flat  epithelium,  in  i 
solid  parts  muscle,  cartilage,  glial  tissue,  and  so  on;  bat  as  a  gener 
rule,  the  solid  teratomas  contain  less  develoi)e<l  tissues  than  the  cysti 
and  are  more  prone  to  malignant  dcvelojjment  with  secondaries 
other  organs.  Cystic  teratomas,  it  is  true,  frequently  undergo  a  ta 
cinomatous  development,  the  tumor  growth  being  of  various  kind 
even  ciiorio-einthcliomatous,  and  the  metastases  may  be  also  of  iiiixt 
nature,  although  sometimes  of  only  one  kind  of  malignant  ti-sii 
Hcfore  leaving  the  "mixed  tumors"  of  the  ovary,  it  may  be  Dointed  oi 
that  there  are  two  kinds,  those  in  which  different  tissues  develo])  iiid 
pendently  and  simultaneously  (mixed  tumors  ])r()n(r),  and  those  i 
which  a  secondary  transformation  occurs  in  the  previously  exi>tir 
neoplasm  (ttmior  in  tumore).  Almost  every  known  combination  i 
benign  and  malignant  growths  has  been  of)served. 

Teratomas  are  liable  to  complications  of  various  sorts;  twisting  ' 
the  pedicle  may  lead  to  anemia,  hemorrhage,  or  necrosis;  inflannniitic 
may  result  in  adhesions  oi  supi)urati()n  with  rupture  into  surroinuiir 
organs,  the  peritoneum  or  to  the  outside.  If  the  more  serious  r(>iil 
do  not  ensue,  there  is  at  least  congestion,  <cdema,  and  the  formation  i 
tlegencration  cysts;  hyaline  or  calc.reous  «legeneration,  also,  may  occu 


liEI.ATKl)  I'KLMC  STRVvriRES 


661 


RELATED    PELVIC    STRUCTURES     THE    LIGAMENTS,    THE    PERI- 

METRIUM,  THE  PARAMETRIUM.  AND  THE  PELVIC  CON- 

NECTIVE  TISSUE 

CoDfenitel  Anoin*.«e8.  -VHrions  nKMlifinitions  of  tin-  liKam«-nts  ran 
'H«nr.  KoveriH.I  hy  v-  absence  or  anomalous  position  of  tlio  more 
Miiportunt  orKiiiis  witi  wl.i.h  they  ure  conn.-ctfHl;  rt-maiiis  of  the 
iMrovariiim  and  the  paroophoron  >nav  xive  ris«'  to  cysts 

CircuUtoiy  Disturbances.  The  veins  in  all  these  structures  nmv  U- 
.liliite.1  tortuous.  tl.roml)os.-.l.  or  (especially  those  of  the  ovarian  or 
lMin[muform  plexus)  the  st-at  of  phlebolith  formation.  Hemorrhace  mav 
:.n.e  from  many  different  causes  connected  with  the  iK-lvic  organs,  and 
the  .  nurse  of  the  W.mkI  vari-s.  ucconliuK  to  whether  it  is  intra- or  extra- 
IMTitoneal       If  u.to  the  iwritoneum.  it  may  gravitate  into  Douclas' 

•' ''.""•'  •'•r"  "  Postuterine  hematoma  or  hematocele;  if  in  large  enoudi 

•IM.M.tity  or  eircumscrilu-d,  it  may  enlarge  the  space  between  the  uterus 
'"'. ,  cX*  "',  «'\.»nt«-«t«'^«  hematoma.     If  extraperitoneal,  it  mav 

iiihltrate, hffusely  all  the  loose  comiective tissue  of  the  pelvis,  or  may  l« 
.<i>v'»-.i  the  layers  of  the  broad  ligament  (intraUgamentous  hematoma) 
In  any  case  the  bloo,|  may  be  absorbed  and  leave  traces  as  pigment; 
nr  •..•lujr  partly  unabsorbwl  may  undergo  organisation  an.l  be  walled 
0  1.  the  occurrence  bemg  marked  finally  by  the  presence  of  a  mass  of 
hl.n.ns  adhesions;  or  while  still  fluid  it  may  rupture  the  wall  of  some 
<'rp.i.  and  escape;  or  being  infected,  may  become  the  basis  of  an 
abscess.  1  he  hemorrhage  of  greatest  importance  is  that  due  to  a 
niptiir  .!  ect.)pic  gestation  sac,  although  bleeding  mav  also  occur  from 
ni|,turc  of  a  Graafian  follicle,  from  a  cy.st.  from  th^  escape  of  blmKl 
rn„,  the  abdominal  end  of  the  tube,  or  accidentally  after  an  opera- 

Inflamniation.-.\ccordii.g  to  situation,  this  mav  Ik-  parametritis- 

li.it  IS,  cellulitis  or  the  i)elvic  tissues,  or  perimetritis,  a  localized  peri- 

t'liiiiis  iittcctni),  the  uterine  serosa. 

Parametritis.     'ilVetion  of  the  pelvic  connective  tissue  ...ises  from 

M.i,M..n  o*  a  goi.orrhccal  or  other  infection  of  the  passage,  or  from 

"Uiin.s  in  p..ifunti"n  or  from  puerpei'dl  sepsis.     The  exudate  mav  be 

>'rn,i.,  or  th<;  tissues  diffusely  infiltrated  with  pus,  or  there  mav  be 

":iii/.d  ah-crss  formation,  and  even  gangrene.     Where  pus  is  foi^med 

m:  .  I.nrrmv  t..  the  abdominal  wall,  the  thigh,  the  floor  of  the  pelvis, 

,',''•  It'"   irf*  ""'\'"™''  "^  ^^'"^  '■''^*'^'"^-     ^^  '^™''"fJ  ^^  ''ix'h  «  state 


tli.ii 

U  r. 

abscf:  s 

faci, 


't  Will  be  at  the  cost    of  much   adhesion   and   fibrosis.       'he 

MiHamed   tissues  of  a   parametritis   are   dinicallv   known   bv 

"'.I  descriiJtivc  phrase,  "the  (inflammatory)  pelvic  m'ass."     What- 

"a  !s  aHccted,  Douglas'  pouili  is  sure  to  ^uJler,  sooner  or  later 

"II  "t  Its  pos^ition,  and  abscess  in  this  area  is  frequent  (retro-uterine 

In  all  these  inflammations,  the  adhesions  are  an  important 


III 


I  1       ,  .  '  "'■■■v.-.iwiia  uic  Hii  important 

a  low  grade  ot  infection  they  may  be  the  chief  abnormal  fact 


002 


THE  REPRODVCTIVE  SY'STEM 


:il 


(productiye  pelvic  peritonitis),  and  may  leail  to  all  sorts  of  distortio 
and  occlusion;  in  an  ordinary  case,  their  position  may  detcrmiii 
the  localization  and  ultiniate  course  of  the  fluid  exudate. 

Progressive  Tissue  Changes. — The  round  lipuncnts  may  hypei 
trophy  along  with  the  uterus,  and  the  broad  lijjaments  with  ovaria 
or  parovarian  cysts. 

Tumors. — The  tumors  found  in  the  hroad  ligament  are  in  the  mai 
derived  from  the  uterus,  where  they  are  not  of  ovarian  origin.  Th 
growths  are  mostly  benign,  myomas,  fibromas,  Upomas,  and  even  adem 
myomas  of  the  tyi)e  already  described  as  originating  in  the  uterine  wal 

Cysts. — Mention  should  liere  be  made  c>f  parovarian  cysts,  which  ari;- 
from  the  i)arovarium.  A  parovarian  cyst  may  grow  as  large  as  a  man 
head.  It  lies  at  first  between  the  abdominal  end  of  the  tube  and  th 
ovary,  and  as  it  develops  the  tube  and  ovary  may  be  widely  separate 
and  greatly  flattened.  There  is  generally  no  {)edicle,  and  the  wall  i 
thin;  internally  the  wall  may  show  papillate  ingrowths.  The  containe 
fluid  is  watery,  and  a  low  specific  gravity. 

Teratomas  ("  dermoid  cysts")  have  been  found  in  the  pelvic  cor 
nective  tissues,  and  sarcomas  can  arise  from  it;  carcinoma  is  al\va\ 
secondarv. 


THE  PUERPERAL  UTERUS 


K;:i 


Apart  from  hemorrhages  connected  witli  the  injuries  of  labor,  ani 
with  imperfect  involution,  and  hemorrhage  due  to  accidental  disturl 
ance  of  the  placenta,  diseases  of  the  puerperal  uterus  centre  arouii 
infection.  As  a  result,  endometritis,  metritis,  or  "puerperal  fever"  jna 
supervt.ie. 

The  otl'ending  organisms  arc  most  often  the  streptococcus  pyogcnc 
and  the  stai)iiylococcus,  and  the  i)redisposing  causes  are  lack  of  cieai 
liness  and  meddling,  nsuall\  in  the  way  of  examination,  douches,  aw 
improi)erly  undertaken  instrumentation  of  the  lining  of  the  uterus.  Tli 
infection  may  be  membranous:  in  general,  the  placental  site  is  hkh 
affected,  the  surface  is  diy  and  gray  or  brown  or  even  green  ii 
color. 

In  addition  to  this,  there  may  be  infection  and  decomposition  d 
retained  fu'tal  products,  blood,  or  lochia.  The  uterus  of  such  a  ens 
is  enlarged,  the  wall  (edematous,  the  endometrium  dirty  green  o 
i)rownish-black  in  color,  stinking  and  pulpy,  the  wall  of  the  uterus  sof 
and  rotten.  Micri>sco])ically.  in  either  case,  the  tissues  stain  badly  aiK 
areas  of  necrosis  or  of  infiltration  are  seen  according  to  the  varyinj 
severity  of  the  infection.  Hacteria  can  usually  be  readily  dcmonstratw 
on  the  surface  and  in  the  tissues. 

In  slight  cases  of  jjuerperal  infection,  there  is  no  such  serious  state 
the  ])lacental  r"te,  it  is  true,  is  ragged  and  unclean  looking,  but  if  drain 
age  be  efficient  the  affection  subsides  with  no  further  onseqm  ikcs 
For  practical  purjwses,  it  nuist  i>e  remembered  that  an  intra-ntoriiK 


.::<i.  jfmx9fiigrmiA» 


THE  PUERPERAL   UTERUS 


663 


lioiiche  at  such  a  time  often  serves  to  produce  an  alarming  state  of 
t(\or  and  rapid  pulse,  due  to  tlie  sudden  release  and  absorption  of 
iiixins;  it  is  always  to  he  rememhered  that  treatment,  to  he  efficient, 
must  inflict  no  further  lesion  on  the  uterine  wall.  Another  extremely 
imi)ortant  fact  to  he  kept  in  mind  is  that  fever  in  the  puerperium  is 
most  likely  to  he  due  to  infection  of  the  genital  tract. 

In  the  pregnant  uterus,  if  the  patient  is  suffering  from  infectious 
disease,  endometritis  may  arise  from  hematogenic  sources;  if  of  low 
LTfide,  the  decidua  may  he  merely  thickened,  hut  if  severe,  purulent 
-ccretion  is  found,  whi(;h  instead  of  heing  discharged,  may  be  retained 
l)(tw(>en  the  decidua>;  hemorrhage  and  abortion  are  likely  to  ensue. 

Metritis.^ — It  will  he  evident  that  any  severe  case  of  puerperal  endo- 
iru'tritis  is  accompanied  by  a  corresi)on(ling  metritis,  which  need  scarcely 
l>f  considered  by  itself,  further  than  to  jxnnt  out  that  the  metrium 
limy  be  the  seat  of  a  diffuse  serous  or  purulent  infiltration  or  of  multiple 
:ilisf(sses;  on  the  other  hand,  the  metritis  may  consist  of  little  more 
tli;m  an  infection  of  the  lymphatics  or  of  the  vessels  with  thrombosis. 
I'nmi  such  beginnings  the  lymphangitis  may  spread  to  the  diaphragm, 
ilif  tlirombophlebitis  to  the  vena  cava,  the  infection  to  the  peri-  and 
Iiiiranutrium,  and  an  extensive  ju'lvic  cellulitis  and  ])eritonitis  be  the 
r(-<iilt;  freq\iently,  and  most  serious  of  all,  a  bacteriemia  arises  (puer- 
jiinil  se])ticpmia). 

Progressive  Tissue  Changes.— Tumors.— The  tumor  specially  con- 
"irtcd  with  i)regnancy  is  the  chorio-epithelioma  malignum,  otherwise 
iiNcd  deciduoma  malifnum,  syncytioma,  syncytial  carcinoma,  and  many 
|>tli(T  names.  It  has  been  elsewhere  explained  (see  p.  213)  that  this 
i>  to  lie  cl.isscd  as  a  teratogenous  blastoma.  When  it  appears  in  the 
uterus  it  is  an  evidence  of  previous  conception,  although  this  may  have 
(Kciirrcd  long  before. 

I  iiis  tinnor  tends  to  form  ])olypoid  or  fungating  growths  projecting 
into  the  uterine  cavity,  but  quickly  invades  the  endometrium  and  the 
lit!  nine  vessels.  It  is  of  reddish  color,  often  hemorrhagic,  and  soft, 
triiililc,  and  spongy. 

TIm'  growth  originates  by  proliferation  of  Langhans'  layer  of  the 
iiMifioiiic  villi;  tliese  cells,  instead  of  undergoing  syncytial  change, 
niMMiii  active  and  proliferative.  After  they  have  proliferated  in  ab- 
'I'liiiiil  situations,  they  may,  it  is  true,  undergo  the  usual  transforma- 
iii'ii-  into  syncytium.  The  deeply  infiltrating  parts  may  show  an  alve- 
"Ih  structure,  but  the  spaces  jjossess  no  special  lining  and  the  tumor 
'i:i  no  struma  and  no  i)lood  vessels.  The  syncytial  elements  when 
I'i'-i  lit  are  in  the  form  of  plasmodial  giant  cells.  The  cells  of  the 
'■  "Plans'  layer  tend  to  be  spherical,  and  are  grouped  into  masses  of 
\  'r  nig  size.  In  the  secondaries,  they  possess  all  their  original  power 
III  i  TiKJon. 

Ml  iitioii  lias  been  made  of  the  readiness  with  which  this  tumor 
'III '  I  !!isi/cs;  tlie  vagina  is  very  often  an  early  seat  of  extension. 


j'vS^iy 


..1^^-i-'-'  'i.<:^^.. 


V.:%.^~.- 


664 


THE  REPROnrcTIVE  SYSTEXf 


THE  PRODUCTS  OF  CONCEPTION 


The  Placenta 


m 


The  patliolojjy  of  tlie  placenta  is  not  very  well  un(!erstoo<l,  am 
few  of  its  morbid  states  are  recognizable  at  first  glance.  Its  size  am 
its  place  are  variable;  its  size,  if  extreme,  is  often  in  keeping  with  that  ( 
the  child;  nsnally  single,  there  have  been  seven  reporteci  with  one  ftrtth 
accessory  j)lacentas  of  small  size  (placentse  succenturiatse)  are  ofte 
seen.  The  position  of  the  placenta  would  be  a  matter  of  little  momen 
were  it  not  for  the  fact  that  its  displacement  causes  ic  '.o  interfere  witl 
the  opening  of  the  uterus,  and  it  is  torn  and  bleeds  at  parturition- 
placenta  previa.  It  is  considered  that  endometritis  is  a  predisposin; 
factor  in  the  occurrence  "f  i)lacenta  previa. 

Circulatory  Disturbances.— Among  vascular  changes,  it  may  be  sai( 
that  jjressure  upon  the  cord  l)y  knotting,  torsion  or  other  means  ma; 
make  the  placenta  anemic  or,  more  probably,  hyperemic,  the  veins  beinj 
more  compressed  than  the  more  resistant  arteries.  Thrombosis  ma; 
result  in  placental  infarct,  a  brown  or  yellow  area  with  altered  blood  do 
that  ultimately  may  undergo  organization.  Hemorrhage  is  the  mos 
important  of  these  circulatory  changes,  because  ett'used  blood  ma; 
separate  the  placenta  from  the  uterine  wall,  and  so  cause  abortion 
(Edema  of  the  placenta  occurs  as  the  result  of  extreme  congestion,  an( 
in  hydramnios  and  cases  of  general  anasarca. 

Inflammation. — Tuberculosis. — Occasionally  in  a  woman  the  subjeci 
of  widesi)rea(l  tuberculosis  the  placenta  may  be  infected  from  the  blood 
and  the  rare  event  hapjjcns  of  a  cUd  born  with  tuberculosis;  sucl 
tul)erculosis  is  congenital,  not  hereditary. 

Syphilis. — Syphilis  leads  to  cellular  infiltration  of  the  placenta;  tin 
arteries  may  also  be  the  seat  of  syphilitic  endarteritis. 

Regressive  Tissue  Changes.— Hyaline  and  fatty  degeneration,  iuui 
necrosis,  followed  at  times  In-  calcification  arc  all  known  as  results  nl 
circulatory  disturbances. 

Progressive  Tissue  Changes. —We  have  already  (p.  211)  called 
attention  to  the  results  of  retention  of  the  placenta  in  the  production 
of  different  forms  of  placental  mole  fleshy  mole,  hydatidiform  mole,  and 
the  chorio-eplthelloma  mallgnum.  For  the  placental  tissue  to  take  on 
other  forms  of  new  growth  is  singularly  rare;  nevertheless,  fibroma  and 
fibromyoma  have  been  described.  The  angioma,  also  recorded,  is  pre- 
sumably a  condition  of  hemangiectasis.  As  regards  cysts,  these  mas  be 
either  necrotic,  secondary  to  localized  infarct,  or  occasionally  in  an 
otherwise  normal  i)lacenta,  the  \illi  of  a  restricted  area  may  slmw 
(edema  and  the  production  of  a  condition  .simulating  the  hydatidit'oriM 
mole. 


^.-•if'.^;.  j£L-: 


mm 


THE  PRODUCTS  OF  COXCEPTIOX 


The  Umbilical  Cord 


GG5 


Fia.  298 


The  cord  varies  jtreatly  in  leiiKtli,  l)<)th  extremes  l)eiiig  trouble- 
■-Dtne  at  parturition;  if  tlie  oniphalo-meseraic  duct  does  not  properly 
close,  the  intestines  may  i)rotrude  into  it  (hernia  of  the  cord).      The 
(liief  interest  in  diseases  or  pathological 
change  seen  in  the  cord  attaches  to  the 
Ixaring   which    these    have   on    parturi- 
tion or  the  state  of  the  ftctus.    Thus  it 
may  he  twisted  or  looped  about  the  tVrtus 
or  some  part  of  it,  so  as  to  cause  even 
amputation  of  a  limb  in  early  fcetal  life, 
or  strangulation  at  birth.    Sometimes  deep 
^rrooves  are  made  upon  the  body  surface 
hy  pressure  of  the  cord. 

Various  degenerations  ot  the  usual  kinds 
may  be  wrought  in  the  cord  by  disturbance 
of  its  circulaticm,  and  septic  infection  of  the 
(lit  end  may  lead  to  infection  of  the  infant 
li\  way  of  the  arteries  and  veins,  which 
licconie  inflamed. 

Syphilis  of  the  cord  is  seen  as  a  small- 
ccllcd  infiltration  around  the  vessels; 
myxoma,  angioma,  and  cysts  are  occasion- 
ally found. 

The  Amnion  and  the  Amniotic  Fluid 

The  amnion  may  press  upon  the  foetus, 
so  that  development  of  a  part  or  parts 
may  lu'  hindered;  actual  adhesions  may 
oi  ciir.  If  the  outflow  of  blood  and  lymph 
lie  ( ilistructed,  giantism  of  a  part  may  ensue. 
Tin  amniotic  fluid  may  be  excessive  in 
anioiiiit  (hydramnios,  polyhydramnios)  or  it 
ma\  lie  diminished  (oligohydramnios).  It 
'iii>  lie  contaminated  by  ftetal  excretions 
^o  ;i-  to  be  dirty  and  foul,  and  may  un- 
<lcr-.i  infection  and  putrefaction. 

The  Foetus 

Hie  death  of  the  foetus  may  be  followed 
'o  IN  expulsion,  but  if  not  expelled,  it 
'III     iiiacerate  and    disintegrate,   coming 

IT     .Irying-up  process  (mummification)  may  ensue,  or  even  cafcifica- 
hthopedion).     Death  of  the  fcrtus  in  utern  is  often  due  to  syphilis, 


Girl,  aged  (en  years,  stiowing  cica- 
tricial grooves  due  to  coustriction  of 
umbilical  cord.  At  birth,  according 
to  the  mother,  the  grooves  in  the  ab- 
dominal wall  and  left  thigh  were  oc- 
cupied by  the  cord.    (Hawthorne.) 


aw.iy   gradually  in   pieces; 


ti 


'] 


ll 


4    " 


." 


~        PI 


KM0i^9<rr>%v«iai;L.>^  >-,-«!^vj<^aB  i-\^,frx&wvii 


000 


THE  REPRODUCTIVE  SYSTEM 


and  various  forms  of  acriti-  or  cliroiiic  (iisease  in  the  mother,  i)ro(hi 
iuK  toxemia,  may  suffice  to  kill  it. 

Ectopic  gestation  may  take  phice  in  any  part  of  tlie  tube,  but  is  mo 
common  at  the  entrance  of  the  tube  to  the  uterus  (interstitial  gest 
tion)  and  in  the  mid  part  of  the  tube.  It  is  not  Hkely  that  abdomin 
gestation  ever  occurs,  the  foetus  that  is  found  in  the' abdomen  havii 
been  extruded  from  the  tube  (tubal  abortion).  To  this  we  have  alreac 
referred  on  p.  052. 

The  chief  (langer  in  ectopic  gestation  hes  in  tiie  liability  to  sevei 
hemorrhage  at  the  time  of  rupture,  and  the  necessity  for  operati\ 
delivery,  for  as  will  be  easily  imagined,  there  are  but  few  cases  th: 
admit  of  expulsion  by  the  natural  channels.  The  causes  of  ectop 
gestation  are  inflammatory,  such  as  the  existence  of  gonorrhoea,  or  son 
obstruction,  either  by  bending  or  folding  of  the  tube  or  by  the  present 
of  a  tumor  or  other  obstacle  to  the  passage  of  the  ovum. 


THE  MAMMART  GLAND 

The  diseases  of  the  breast  belong  alike  to  both  sexes,  but  by  reaso 
of  its  function  in  lactation,  the  female  breast  becomes  of  prime  import 
ance;  in  the  male,  a  consideration  of  its  diseases  would  be  a  very  simpl 
and  brief  matter.  The  mammary  gland  is  branched,  and  at  the  onse 
of  pregnancy  the  single  lobes  become  compound  and  many  new  acir 
are  formed,  while  the  vascularization  and  stroma  advance  equally  i 
their  development;  at  the  time  of  delivery,  the  first  expression  bring 
from  the  gland  colostrum,  in  which  the  "colostrum  corpuscles"  ar 
cells  that  have  wandered  into  the  acini  and  have  engorged  themsclve 
with  the  fat  corpuscles  that  lie  therein;  after  their  dislodgement,  th 
globules  are,  in  the  regular  way,  the  product  of  the  mammary  cells 
When  the  function  of  lactation  is  finished,  the  breast,  as  a  wliolt 
becomes  smaller  and  once  more  simplified. 

Congenital  Anomalies. — Amazia  or  amastia,  absence  of  the  breast 
often  bilateral,  is  generally  associated  with  lack  of  ovarian  develop 
ment,  and  hypoplasia,  the  infantile  breast,  accompanies  an  infantile  stat 
of  the  sexi  ?!  organs  in  general.  Microthelia,  an  abnormal  smallness  o 
the  nipple,  may  lead  to  difficulty  in  suckling.  Abnormal  developnien 
of  the  breast  in  the  male  (gynecomastia),  reduplication  of  the  nipi)l( 
(polythelia)  or  of  the  breast  itself  (polymastia)  are  observed.  Accessor] 
breasts  may  be  seen  in  such  a  situation  as  the  axilla,  from  pinched  of 
lobules  (aberrant  mamma),  and  such,  as  weil  as  the  ordinary  super 
numerary  breasts,  can  produce  milk. 

Circtilatory  Disturbances.— Swelling  of  the  breast  sometimes  charac 
terizes  the  premenstrual  period,  and  occasionally  vicarious  menstru 
ation  is  exhibited  by  discharge  of  blood  from  the  nipple.  Hemorrhag* 
and  the  formation  of  hemorrhagic  cysts  may  result  from  trauma  citliei 
primarily  or  by  bleeding  into  a  preexistent  cyst. 


?^tat^.. 


m 


wim, 


TlIK  MAMMARY  GLASl) 


ti(j< 


Inflammation.— Inflammation  may  arise  in  the  breast  at  any  period 
of  life,  even  in  infaiiey,  hut  it  is  most  often  found  durinj,'  iuctation, 
where  infection  gains  entrance  throufjli  the  nipple  canal,  or  more  fre- 
(luently  by  way  of  small  fissures  or  cracks  in  the  nipple.  Rarely  the 
hreast  suffers  by  extension  of  inflammation,  as  where  the  infection'from 
ii  carious  rib  or  a  ruptured  empyema  reaches  its  tissues.  Thelitis, 
iiiHammation  of  the  nipple,  and  areolitis,  of  the  areola,  occur,  with  the 
formation  of  abscess,  the  so-called  antemammary  abscess.  Inflamma- 
tion of  the  breast  tissue  itself  (mastitis)  is  the  most  common  form;  the 
l)reast  is  enlarged,  tender,  and  sometimes  reddened;  it  may  be  possible 
to  press  pus  from  the  nipple  (galactophoritis  purulenta),  or  there  may 
iiiirely  be  evidence  of  a  deep  al)scess  or  of  several  such;  more  rarely, 
the  entire  breast  is  in  a  state  of  purulent  infiltration  ';mastitis  phleg- 
monosa).  However  the  infection  may  have  reached  the  breast,  the  inter- 
stitial  tissue  is  seen  microscoi)ically  to  be  infiltrated,  while  the  glands 
contain  a  semipurulent  material  in  which  are  abundant  desquamated 
(Icgenerat. .'  gland  cells  and  leukocytes.  If  the  disease  be  not  relieved, 
the  abscessMs  may  coalesce,  and  the  entire  breast  be  riddled,  and  the  pus 
niiiy  travel  far  for  an  oi.tlet,  may  break  through  the  skin  or  even  into 
the  thorjix.  An  opening  into  the  skin  may  establish  a  fistula  through 
which  milk,  mixed  with  inflammatory  products,  may  escape.  A  non- 
Mippurative  mastitis  may  quickly  resolve;  abscesses' if  evacuated  mav 
111  .il  with  scarring,  and  it  not  evacuated,  the  pus  may  inspissate,  and 
nilcareous  deposit  occur;  in  a  nuich  scarred  breast,  the  onset  of  a  new 
pnijuancy  may  be  attended  by  the  development  of  retention  cysts. 
I  he  so-called  retention  mastitis  is  nothing  more  than  infection  of  a 
liniist  in  which  there  is  already  an  irritation  caused  by  the  presence  of 
-tiiiinant  gland  secretion. 

Tuberculosis.— Tuberculosis  occurs  with  fair  frequency  in  the  breast, 
""  asionally  as  diffuse  miliary  tuberculosis,  but  oftener  as  caseous  areas, 
^nid  as  cavities,  from  which  fistula^  may  op<-n.  The  edges  of  the  fistula 
arc  covered  by  granulation  tissue  and  the  discharge  is  thin  pus.  The 
iiMlliiry  lymph  nodes  also  show  caseation,  and  may  even  break  down 
;ni(l  .lischarge.  In  the  case  of  both  these  forms  of  tuberculosis  the 
ml.  ( tion  is  hematogenic.  Syphilis  may  occur  on  the  nipple  as  the 
primary  lesion,  and  ditfuse  and  gummatous  infiltrations  mav  arise  in 
till'  l.reast  in  the  later  stages,  while  the  skin  of  the  breast  mav  exhibit 
^piiifu;  changes,  as  the  skin  elsewhere. 

Regressive  Tissue  Changes.— Atrophy  of  the  mammary  r,land  occurs 
iit  \\\v  menopause  and  sometimes  after  removal  of  the  ovaries,  although 
tiH  loss  may  be  compensated  or  overcompetisated  in  bulk  b\  fat, 
without  which  the  breast  becomes  small  and  flabl)v.  Microscopically, 
t  M.  k.iinig  and  hyaline  degeneration  of  the  walls  of  the  ducts  occur,  so 
'hit  tliiv  appear  as  yell()wi->  -whi.e  lines  in  the  tissue. 

Progressive  Tissue  C"-  ^  'legeneration  i  destroyed  tissue 
'""ir-  only  to  a  slight  e>  ,  .  pensatory  hy|;_. trophy  of  the  rest 
"'  'l|'  «land  IS  a  more  frequ.  >t  happening,  and  is  not  confined  to  preg- 


l    ! 


^n^syik^i^' ..^i^^^;^ 


60S 


ruE  nEPRonrcriv   '<YSTE^f 


nancy  hut  may  happen  in  cast-s  of  new  >;ro\vtli  of  the  uterus  and  ovarie 
l{ar«'  cases  arc  ohserved,  usually  in  the  young,  of  a  kind  of  neoplast 
overgrowth  (giantism  of  the  breast)  in  which  a  hreast  lias  attained 
weight  of  sixty-four  pounds.  There  is  also  diffuse  overgrowth  that  soni 
times  is  of  the  nature  of  fibromatosis,  at  others  of  adenomatosis,  or  ( 
both  together.  The  nipple  does  not  share  in  the  general  enlargemeii 
Tumors. — These  are  of  considerable  c()mj)lexity  and  of  great  praetici 
impo'-tance  because  of  the  preponderance  of  malignant  forms  of  growtl 
because  they  are  readily  iircessible  to  surgical  removal,  the  patholi 
gist's  opinion  is  frequently  asked,  and  the  decision  is  often  very  difficu 
to  make.  Because  of  the  liability  to  error,  and  the  frequency  of  malij 
nant  tumors  in  this  site,  it  has  become  a  surgical  rule  to  advise  t\ 


Fibro-adcnoniii  nf  l>rraHt  iifTnrdiTiK  indiciitioiis  of  ovcrKrowth  und  ahorrant  growth  of  the  glatKiuI; 
clcnipnts:  n,  ciiniiirfswd  acini;  h,  Kl>ri>u9  iiveriinmtli;  r,  a  Biiniiwhat   dilated  durt,  with  epitbeli 

proIif<'rution. 

removal  of  any  growth  whose  nature  is  at  all  doubtful.  Although  tli 
male  breast  is  able  t()siiowexanii)les  of  all  the  tumors  to  which  the  feniiil 
breast  is  liable,  it  docs  so  relati\ely  infrequently;  the  latter  is  in  a  stat 
of  physiological  and  anatomical  instability  throughout  the  years  c 
sexual  activity,  and  is  liable  now  to  progression,  now  to  recession  n 
vegetative  activity,  which  is  i)recisely  the  state  of  affairs  in  whidi  w 
have  indicated  a  "habit  of  growth"  as  likely  to  arise.  Because  of  it 
cxj)()scd  position,  a  history  of  trauma  frequently  precedes  the  develop 
ment  of  a  tumor,  and  the  association  has  been  accorded,  especially  b; 
the  laity,  an  importance  that  is  probably  uiidt-scrvcd.  Among  priniar 
growths,  the  epithelial  are  most  in'i)ortant,  and  consist  of  fibroadeiioinas 
adenomas,  cysts,  and  carcino'.ias. 


THE  MAMMARY  GLASD— TUMORS 


009 


Fibro-adenomas.— 'I'licse  are  growtlis  from  the  size  of  a  cherry  stone 
to  that  of  a  wahiut,  liard,  soinetiriu's  nodular  on  the  surface,  readily 


Fia.  300 


P.riranalicular  fibroma  of  the  mammary  gland.  The  Klandular  acini  and  ducts  are  prominent 
aiul  sl,o«  some  irregular  overgrowths  of  the  epiih.lium,  Imt  the  main  feature  is  the  development 
of  cuuneclive  tissue  both  periacinous  and  interstitittl,  the  latter  not  sharply  defined.      (Ribberl.) 

Fui.  301 


Intraranalicular  fibroma  or  intracystic  papilloma  of  breast.     (Orth.) 

,''.''.''  "V*^  ''"'""  "'^^  surroundnig  tissue,  which  on  section  have  a  very 
'I'S'iiitf  fihrous  structure;  between  the  fibrous  bands,  the  glandular 


"C3S 


070 


THE  REI'ROnVCTIVE  SYSTEM 


li 


tissue  protrudes.  It  will  he  at  once  evident  tiiat  the  term  fibroadeiioii 
implies  that  not  only  is  there  ov«rgro\vth  of  the  fibrous  tissue,  but  al.- 
of  the  gland  tissue,  and  it  requires  n)nsideral)le  experience  to  be  sin 
of  this  on  microscopic  examination.  Pure  fibroma  of  the  l)reast 
rare;  nearly  every  fibromatous  growth  includes  in  it  some  glanduh 
structures  which  necessarily  becona-  distorted,  pressed,  and  lose  soin( 
what  of  their  orderly  arrangement;  there  will  be  all  grades  seen  betwee 
a  very  fibrous  growth  containing  few  acini  and  a  slightly  fibrous  growt 
showing  many  acini,  yet  all  alike  may  be  classed  as  adenofibroniii 
It  is  customar\  to  divide  these  growths  into  pericanalicular  and  intri 
canalicular  adenoflbromas.  In  the  pericinialicnlar  form,  single  glan 
acini  are  snrroun.ltd  by  a  thick  hiy.r  (.f  ceiluhir  fibrous  tissue,  whil 
in  the  intracaiialicular  form  tlieic  arc  papilloma-likc  j)rojections  ( 
proliferated  stroma  covered  by  proliferated  gland  epithelium  e.xtendin 
into  the  lumen  of  the  ducts. 

l)egenerati\e  or  other  changes  in  the  structure  of  the  tissues  formiii 
these  tumors  give  origin  to  various  modifications  such  as  adenomyxe 
fibromas,  adenolipofibromas,  and  adenofibrosarcomas. 

Pure  Adenomas.— Tliese  are  comi)aratively  rare,  and  are  solid,  o 
cystic.  The  solid  forms  approximate  somewhat  to  the  fibro-adenonia:- 
but  arc  distinguished  by  the  extreme  increase  of  glandular  tissue 
The  cystic  form  (cystadenoma  papilliferum)  is  characterized  by  tin 
l)resence  of  cysts  on  the  inner  walls  of  which  there  are  small  pai)illo 
matous  or  jiolypoid  j)rojcctions. 

Cysts.— If  all  sorts  of  cysts  are  here  considered,  it  is  needful  to  men 
tion  milk  cysts  (galactocele)  which  arise  by  blocking  of  a  duct  durin« 
the  time  when  secretion  is  acti\c.  These  arc  true  retention  cysts 
Of  another  kind  are  the  involution  cysts  found  in  achanced  years;  tliix 
appear  as  usually  multiple,  bilateral,  hard  small  masses,  riot  capal>l( 
of  i)eing  shelled  out  and  on  section  cystic,  with  variously  colored  Hui«i 
the  state  in  which  these  cysts  dcveloj)  is  called  chronic  cystic  mastitis. 

Carcinomas.  1.  Gland  Carcinoma.-  This  arises  most  commonly  in  tin 
fourth  and  fifth  decades  as  a  firm,  ill-defined  mass  in  the  breast  not 
easily  movable  ixptirt  from  the  rest  of  the  gland.  Frequently,  tlun 
is  a  relatively  early  indrawing  of  the  ni|)ple.  The  growth  becomes 
more  superficial,  and  as  it  does  so,  the  skin  until  now  freely  movable 
over  the  tumor,  becomes  fixed  to  it,  and  carcinomatous  masses  ai)pear 
as  knobs  in  the  skin.  Without  complete  removal  by  operation,  the  car- 
cinoma may  spread  ditinscly  through  the  skin  and  subcutanecuis  tissue 
forming  a  dense,  ix.ard-likc  mass  (cancer  "en  cuirasse").  Sometimes 
the  growth  breaks  through  the  skin  in  a  fungous  mass.  Necrosis  ami 
ulceration  are  [)ronc  to  occur.  The  lymph  nodes  nearby  are  early  infil- 
tratcfl,  not  only  the  axillary  but  the  supra-  and  infraclavicular  groups, 
as  well  as  the  pleura,  the  other  breast  and  the  underlying  muscle;  the 
secondaries  exhibit  a  tendency  to  attack  the  bones. 

Microscopically,  om>  may  (h^tinguish  a  soft  rapi<}ly  growing  (medul- 
lary) form  and  a  hard,  slowly  growing  (scinhous)  form,  between  whicli 


THE  MAMMARY  CLASD 


071 


Viliriociiriinoiiia  uf  imimmary  gland-  a,  b,  cancer 

Fig.  303 


acini  with  niuliiplc  lumen  funnaiion. 


f    } 


i* 


\  -  V  .. 


--,^- 


/-.^. 


«9 


";::;s^'SS;::;r:;Si;;it^;;--i:-~;'-- 


^     ' 


4L'«Tsirc .  vaK.jw.^:sKX-:r- 


^^^^^SSSS^^SB 


(•.72 


TIIK  RKl'RomVTIVK  SYSTEM 


arc  ull  (legn-es  of  variation.  When  lu'ithcr  vt-ry  H(»ft  nor  obvious 
fibrous,  the  growth  is  usually  dt'iioininatotl  carcinoma  simplex.  Tl 
soft  tumors  utv  wliitisli,  and  exude  milky  juice,  while  the  scirrhoi 
ones  are  fibrous,  scar-like,  and,  if  in  the  region  of  the  larger  <luct 
tend  to  retract  the  nipple.  Microscopically  in  a  medullary  carcinon 
the  carcinoma  cells  may  l)e  diffuse  or  arrangwl  in  an  alveolar  or  a  tubuli 
manner;  in  scirrhous  tumors  often  in  mere  lines.  The  new  growth  mii 
inva«le  the  larger  ducts  and  infiltrates  among  the  fatty  tissues;  secondai 
infiammatory  reaction  is  often  seen  (p.  20.')).  The  scirrhous  form 
inodifietl  only  in  this  particular  that  there  is  a  parallel,  strongly  pr 
gressing  process  of  healing  by  fil)rosis  going  on,  so  that  in  a  field  tl 
carcinomatous  alveoli  or  tubules  may  be  surprisingly  scanty.  Psaii 
momatous  IxHiies  and  colloid  change  are  rare  nKxIificatitms. 

2.  Squamous  Carcinoma  of  the  Nipple  and  A/eola  (Paget's  disease  < 
the  breast). — These  terms  are  not  exactly  synonymous,  but  Pa^et 
disease  includes  most  of  the  cases;  here  it  seems  as  if  a  s(]uamot 
carcinoma  arose  from  the  lining  of  the  larger  duct  mouths,  tending  1 
ulcerate  and  spread  superficially. 

Other  Growths. — (Irowths  other  than  epithelial  are  rather  uncommoi 
Fibroma  has  been  referred  to;  sarcomas  of  the  various  kinds  are  seei 
as  well  as  endo-  and  peritheliomas,  chondromas,  and  osteomas.  Melanom 
arises  occasionally  in  the  nipi)ie  or  areola. 


Kmi^^B-,.^,.^..  wBgA.  .  ya 


<11  AI'TKU    X  I  I 

THE  MOTOR  AND  TEGUMENTARY  SYSTEMS 


THE  MUSCLES 

TiiK  aimtc.inical  muscle  is  made  up  of  numerous  bundles,  each  of 
wlM|li.  11.  turn.  ,s  made  <.f  individual  muscle  cells;  the  bundles  are 
lin.l  to  one  another  by  a  fibrous  tissue  network,  lodging  fat  vessels 
a...l  nerves  the  perimysium;  the  individual  fibres  or  cells  are  similarly 
li.  1.1  together  by  the  emh.mysium.  The  individual  fibre  cell  =s  difler- 
.Mtiated  mto  the  fibrils,  which  carry  the  transverse  striations.  the 
>,in.. plasm  or  cement  substance,  and  the  sarcolemma.  The  fibre  is 
I"  ivnuciear  the  oval  nuclei  arranged  in  rows  close  to  the  inner  surface 
«>l  t he  sarcolemma.  1  he  size  of  muscle  fibres  differs  enormousl v  The 
muse  e  spindles  are  structures  distinguished  from  the  other  fibres  bv 
MiiiM  size  and  a  thick  perimysium;  innervated  from  the  sympathetic 
sysi...,,.  It  IS  thonglit  that  they  may  be  the  orgar  of '"muscular 
sniM-  After  death  as  soon  as  a  couple  of  hours  in  the  young,  the 
m>nall,nir,„s  coagulate,  so  that  in  a  short  time,  the  muscles  are 
firii.  an<  rigiu  (ngor  mortia),  a  condition  which  passes  off  after  a  day 
"r  V,.     1  he  muscle  fibre  is  rigid  and  shortened. 

The  muscles  are  much  exposed  to  trauma  and  to  infection,  but  they 
nr..  u.H  protected  by  the  tissue  juices  and  the  free  circulation.  The 
iuiimI,.  whose  innervation  is  interfered  with  is  by  no  means  so  immune. 

Congenital  Anomalies  -These  are  so  numerous  as  to  forbid  detailed 
'!<  -  ription.  Absence  of  a  whole  muscle  or  a  part,  reduplication,  abnor- 
mal onirin.  insertion,  or  size  include  most  of  the  modifications  found- 
mn-'  I's  may  appear  in  man  which  are  normally  found  only  in  some 
'■tiH  r  spt-cies.  1  he  one  muscle  whose  importance  entitles  it'to  special 
I-  "ii.m  ,s  the  diaphragm;  defect  of  this  muscle  may  vary  from  a  small 
'  l-n,n,^  to  a  lack  of  almost  an  entire  half,  so  that  the  thoracic  and  ab- 

' '"'  '"''.t'^  f  f  ff^'ly  communicative.  We  have  seen  ai  autopsy  a 

<  ongenital  defect,  with  many  abdominal  organs  in  the  thorax,  in 


'j'Hi  ..t  P^ore  than  fifty  years  who  had  some  reputation  as  an  athlete 
IN    Numiger  days;  to  so  much  can  the  body  become  accustomed 


Circulatoiy   IMsturbances.-Anemia  of  the  muscles  of"~more"than 
■i'jTary. juration  rarely      curs  apart  from  generalized  anemic  states 

t  ■     '■■  "■   ShI  n^v  ''  '"  f'^^'^'f-^  endarteritis  of  many  vessels. 
...,»,  supply  may  be  continuou.siv  restricted. 
Hyperemia  occur.,  in  and  ;.bout  are.s  of  inflammation,  and  in  states 
"I  I', -.ivc  congestion. 

4y 


iz^s^^m^: 


674 


rut:  MOTOR  AM)  TEC.UMKSTAUY  SYSTEMS 


HsmoRhage  is  usually  of  trauiiuttio  origin;  if  a  large  amount  of  l>l( 
be  extravasated,  a  hematoma  results;  this  may  Im>  al>sorlH-<l,  and 
part  heal  with  fibrosis,  or  may  lie  iiifeeted  with  ahseess  formation,  i 
cyst  may  rlevelop.  Smaller  hemorrham's  (petechue)  are  of  other  ori) 
They  are  found  in  eases  of  jjreat  hyperemia  and  of  ^tvoX  anemia, 
very  severe  toxemias,  and  haeteriemias,  hut  are  less  readily  seen 
muscles  than  in  whiter  tissues.  Infarct  is  infre(|uent,  because 
muscles  have  a  j;oo<|  collateral  blood  sup|)ly;  in  eases  of  widespn 
thrombosis  or  a  general  sclerosis  of  many  vessels,  infarct  may  devel 
and  may  even  lead  to  pmgrene. 

Inflammation.—  Myositis.  'I'he  changes  which  characterize  a  sli 
myositis  are  those  of  the  connei-tive  tissue,  the  muscle  entering  into 
process  only  by  showing  u  cloudy  or  other  deg«'neration.  In  snppi 
tive  myositis,  abscesses  occur  by  extension  from  |K'riosteal  or  celhil 
infections  or  as  a  part  of  a  general  bacteri  »nic  process,  but  in  this  I 
the  muscles  escape  better  than  do  other  solic.  organs,  {H-rhaps  becaus* 
their  activity  arousing  hyperemia.  The  abscesses  are  circuinscril) 
or  there  is  a  diffuse  necrosis  pHxluced.  The  process  of  healing 
attended  by  fil)rosis. 

Chronic  myositis  is  exemi)lified  by  such  an  inflammation  as  is  s( 
in  arthritis  deformans,  where  there  is  a  progressive  thickening  of 
perimysium  and  an  inflammation  of  the  endoniysium  with  degcnerat 
of  the  fil)res;  it  may  be  seen,  too,  in  the  neighborhood  of  any  proe 
of  a  low  degree  of  acuity.  Here  may  l)e  mentioned  those  ptcul 
cases  of  myositis  which  result  in  the  growth  of  bone  in  a  nnis 
such  as  the  adductor  (rider's  bone),  and  the  strange  disease  eal 
myositis  ossificans.  These  it  will  be  renieml)ered  are  rather  exainii 
of  metaplasia  than  of  true  inHanunation,  even  if  in  tlu  former  ci 
there  is  a  continued  irritant  at  work. 

Acute  Polymyositis.-^ This  is  an  ill  understo(Kl  and  rare  flisease,  eh 
acterized  by  spontaneous  multiple  swellings  of  the  muscles  of  inn 
parts  of  the  body,  with  loss  of  motor  power,  accompanied  by  urticai 
swelling  of  the  skin.  There  's  a  marked  (edema  of  the  muscles  w 
round-celled  infiltration  and  jjotcchial  hemorrhages,  and  vacuolati 
of  the  individual  fibres. 

Trichiniasis. — This  is  a  widespread  inflammation  of  the  muscles  i! 
to  the  presence  of  a  systemic  infection  by  Trichina  spiralis.  The  wor 
obtain  entry  to  the  muscles  and  there  encapsulate  themselves,  anpeari 
as  tiny  white  or  gray  dots;  microscopically  the  coiled-up  worm  can 
seen  in  its  capsule,  which  is  thick  and  chitinous;  in  the  muscles  arotii 
esi)ecially  when  the  parasites  are  numerous,  there  is  a  great  cellu 
infiltration,  accomi)aniiHl  by  degeneration  of  the  muscle  fibres,  some 
which  are  degenerated  even  if  not  directly  attacked  by  the  parasi 
The  nuclei  of  tin;  muscle  fibn  s  are  ordinarily  multiplied. 

Tuberculosis. — Tuberculosis  of  hcmatogetiic  origin  is  not  verj'  comnn 
but  may  be  part  of  a  generalized  infection;  the  muscles,  however,  ev 
here  seem  to  be  fairly  self-protecti\  e.     Generally  the  disease  is  seeonda 


I  iHiiii  III  i^Miiiiiiiiiiii  III  (iiiiiii  III  ■■  I  111  mil  I  mi  I II  III  I  iiiB  III  I  ■■■III  I  ill  III  mi  I II I 


t^iXi; 


THE  MISCLES 


675 


t«  aiul  ,n  the  nnRhfKjrh.KKl  of  tuln^rculosis  of  the  l.,„.es  and  joints 
« lun.  .t  takes  the  form  of  .small  or  larKe.  caseou.s  are  .  .  The  U  ♦  nl 
ana  ..f  Mipi.uration  is  eulle.I  u  '(•oM"  ahseesH  the  iL  rJJZhl^h. 

::::i'u  is'"""""-  "*■'•"•"  •"••  ■"•-•  l-X' ^.I'ts; 

Syphilis.-  The  form  usually  assumed  hy  syphilis  in  the  muscle  is  th. 
nmm..  although  a  .lifru.sc  inflammatory  form  is  a"so  LT  111' 
in  the  n,usdes  reaches  its  Kreatest  .limensions.  and  its  progre  s  a  ,  "h  7 

OlanderB  an.l  Actinomycosis.-Thes.-  otcasic.nally  give  rise  t.,  slowh- 
tDriiimj;  abscesses.  "  siowi;\ 

Parasites. -Apnrt  fron,  trichina,  cystieereus  and  echinocKcus  are 
><<  II  occasionally  m  the  nniscles  »-^"mot.x.cus  are 

Regressive  Tissue  ChMges.- Atrophy.- Atn.phv  of  muscles  „s  a 
«Ii    <•  occurs  u.  old  age.  or  in  cases  of  inaniti.m.  ixcVllentlv  exemplified 

or  n3*?1"  "*"'"^'''  ■'•'  *^'  '"""  ^"'"S*'*  «'"•"*  »'>■ '«-«"'"  "f  the  central 

':';:::';.::.'?;;;h.mr^ii;;T.ir^^^^ 

l-'m^tlfli^^en.'r  m  """  ^--u^es  there  are  certain  fundan.ental 
.'  iiri>  t<   l,t  u'eii;  the  hl.res  are  shrunken  hv  loss  of  contractile  si.h 

"-"  i'-  «  ?  simyl'?'"-    ^^f  f  "'lemma  and  the  nuclei' remain 

j:ran,,|..!:     et.  he  S"  a^opposedt,,  degenerative  atrophy,  no  such 

^n'!°n>  tr:t;^c"letl?HTn"'*  "/  "'r'^^  ""^^  intoxications,  there 

.    I  '"  '"'"'''e  '"  «eet'f  «i'"> ;  such  a  state  often  progre-e«  ann^r- 

-■■■      ..   at  y  degeneration,  in  which  the  fat  droplets  may  be" sSTn 


676 


THE  MOTOR  AND  TEGVMENTARY  SYSTEMS 


Waxy  Degeneration  (Zenker's  Degeneration).— This  is  obscrveci  espt- 
ally  ill  the  rectus  abdominis  and  adductors  in  typhoid  fever,  less  oft 
in  other  infections  and  in  trauma.  The  muscle  is  parboiled  looking,  pi 
and  waxy  in  appearance.  Microscoj)icaily,  entire  fibres  or  parts  of  fibi 
are  seen  to  be  ill-stained  and  of  a  uniformly  waxy  appearance,  t 
contractile  substance  appearing  to  have  undergone  a  coagulati^ 
necrosis.  Transverse  rupture  of  tiie  fibrilhe  appears  to  occur,  althoUj 
some  hold  that  this  is  an  artefact.  The  occurrence  of  small  hematomi 
however,  is  strongly  against  this  supposition. 

Progressive  Tissae  Changes.~The  regenerative  processes  of  mus( 
have  been  discussed  elsewhere  (p.  197).  Hypertrophy  of  a  muscle  fni 
increased  work  in  the  presence  of  adequate  nutrition,  consists  in 
broadening  and  lengthening  of  the  individual  cell.  Debate  still  exi^ 
as  to  whether  or  not  a  numerical  increase  of  fibres  occurs. 

Tumors. — Primary  tumors  of  muscle  are  not  very  common,  and  t 
fibromas,  myxomas,  and  angiomas  that  are  observed,  as  well  as  the  lipoini 
arise  from  the  coiniective-tissue  structures,  the  peri-  and  endomysiui 
etc.  Rhabdomyomas  originating  from  the  muscle  cells  are  singular 
rare.  Sarcomas  of  various  kinds  may  be  found,  and  while  we  ha 
found  rhabdomyosarcoma  in  the  trout,  its  occurrence  in  man  is  litt 
known.  Secondary  sarcomas  and  carcinomas  are  not  common,  save  I 
extension. 

THE  TENDONS  AND  TENDON  SHEATHS 

'J'he  tendons  are  relatively  a\ascular  bundles  of  strongly  united  pa 
allel  fibres,  held  together  by  a  small  amount  of  connective  tissue  wliii 
carries  the  blood  vessels,  the  interfascicular  tissue,  and  which  fori 
an  external  covering,  the  ju'rifascicular  tissue.  The  tendon  is  encl()S( 
in  a  dense  fibrous  capsule,  between  which  and  the  tendon  is  a  space  filii 
by  synovial  fluid  which  serves  as  a  lubricant.  The  tendon  slieai 
cavity  is  thus  one  of  the  synovial  spaces,  and  as  such  is  very  like  tl 
joint  cavities  and  the  bursa'.  Hy  reason  of  their  little  vascularii 
they  are  not  prone  to  infections  of  a  primary  nature. 

Inflammation.  —  Tendinitis    and    Tenosynovitis    (Tendovaginitis). 
Despite  the  name  tendinitis  the  tissue  of  the  tendon  practically  pla; 
no  part  in  inflammatory  processes,  which  concern  chiefly  the  inte 
fascicular  tissue  and  the  sheath. 

Acute  Tendinitis  and  Tenosynovitis. — This  is  an  exudative  inflammatii 
with  fibrinous,  serofibrinous,  or  purulent  exudate.  The  less  sexci 
forms  may  evidently  arise  as  primary  diseased  states  in  rheinnatisn 
and  from  trauma,  while  the  purulent  forms  are  usually  by  extensioi 
or  by  infection  from  penetrating  wounds,  rarely  hematogetiousi; 
With  a  fibrinous  exudate,  "dry  tenosynovitis,"  the  fibrin  forms  a  thi 
layer  between  the  moving  surfaces,  and  motion  gives  rise  to  cr('i)iti 
tion.  It  is  (|uite  often  seen  in  the  extensors  of  the  thumb  and  haiu 
The  serofibrinous  form,  in  which  there  is  some  fluid  cxuilatc  in  the  slieat! 
is  oftenest  seen  in  the  flexor  tendons  of  the  hand;  when  absorption  of  th 


THE  BURS^ 


677 


.natly  limit  mc,veinent,  Zil  n  Sfh^  T"^  '^'jf"*''-  These  may 
""■•'t  they  become  length,  ed  thireH  \'  "'"^"'"«"ce  of  move- 
.'l-Ijear.  ^^^rulsr^  ter^^X^  ^^/':;  ^^''^  "^^y  Anally  dis- 
="i<l  its  danger  lies  in  the  hcttLtVu  ''  "*  J""»' '-'*  exudate, 

.'••  the  interfascicular  sub  a  ce  ^ ith^^^^^^^ '  n  '  ""TTl '  f  ''«^^*'- 
-  ..mponent  parts  and  necrosis  even  of  thS  ""'"  *^  "^""  '"**^  '^^ 

^.•.S^fsStHiirJis;"  ?".f  ^'•^•''^"'''^  «*'  ^'^^  -"  a-1 

sheath).  The  organizing  itess  and  th  '  "'  ^"r**"^*  ^^^  ^'^  ^"-^'^ 
MKh  a  case  may  lead  to  thnnrlf?  overproduction  of  tissue  in 

« I'ich  become  grated  off ^^^^  "^  ^f'^"'"^  T^  P'^P^'ate  bodies 
sms  are  called  "rice  bX  "  iZj^  """^T^'  ^'!^^'  ^'"'^  ^'^^  '"  the 
•  rated  cells  Calcl-M»t  rt««.  -f  "'^  ™"*''^'  ''>«''"«  "masses  of  degen- 
inflanunation.        ^"^  ''^''*  '""^  "^^•"'- ««  "  '•^^"It  of  a  long-conti/ued 

■-""J^SS'-^nlirS^^^^  can  be  prima.,, 

•■'m>i.st  of  a  diffuse  inflammatTon  wifh^r  •?  "\"*'^'"^^'-  ^^  ™ay 
ti-.u'  which  fills  the  cavitv"md  co^^  s  tl  !'r  T"*,^  ""-^  g'-anulation 
f»ue  of  the  tendonmav  i,ec  IhJeL^^  *'"'.?'  *''«  interfascicular 
-■•  The  soft  gra,„datio„  t^Z  "  ad^^'il^f  ^7'°"  -"ease  in 
IToccss  may  ensue  and  finally  bnUtfJ^l  ^  .  "^f  '  ^'"'^  **  suppurative 
More  rarely  tubercul  1  ma  ^1  ow  Jti?^  ''^'  '"P".';^^'^'  structures. 
■'•  >'-v  progression  and  TcL  na  iirhv':  ^'7""^"^  overgrowths 

■Ti-  hodies,"  spoken  of  XvfZ  be  the"      f'T^    ^'"""^■'  ^^e 
pn„rss.  *"'  ™'^'^   ''^  t'l''  product  of  a  tuberculous 

"I  il"'  ^liralli.  inKctio.1,  later,  gumnias  occur  on  the  wall 

*■"  ."„)  I,e  a  prcJicrSZlorMiif, '■''''''*■'•''■?'"''•  '■'''""■"''""■ 
"«  "  »M-  ill  size  of  the  tejidoi,       """"^*"'  '"""e  ""I  a  corresponding 

^li>  ill h.  '^  '  " "  '^c'l ;  lipomas  occasionally  arise  in  the 

^^'-'■•'1  fluid;  it  i;  frequltly  see     on    'hri;    i;"T 

ganglion,  an,!  consists  of  a  her.S  nouch  uhn       ""^ u^-'  ""'"'''  '"^^ 

•!'>'"  'If.!  tendon  sheath.  ^  ''^""^  '''*•"  '«  "'"'^e  "f  the 


THE  BURSA 


078 


THE  MOTOR  AND  TEGUMENTARY  SYSTEMS 


pressure,  such  as  is  caused  by  the  phiy  of  a  tendon  on  a  bone.  Th( 
l)ec()nie  lined  by  a  definite  en(h)theliuni,  and  l)eing  perfectly  analogoi 
to  the  tendon  sheaths,  they  are  subject  to  much  the  same  processes  ( 
disease.  Fibrinous,  serofibrinous,  and  i)nrulent  exudates  occur 
inflammation  of  the  bursa?,  under  conditions  similar  to  those  uwd 
which  tenosynovitis  occurs,  with  the  difference  that  the  bursae  are  moi 
exposed  to  trauma  than  are  the  tendon  sheaths.  Chronic  bursitis 
characterized  by  much  thickening  of  the  walls  and  a  considerable  amoui 
of  exudate,  so  that  a  large  swelling  may  be  produced  at  the  site  of  tl 
bursa  (hygroma).  "  Housemaid's  knee,"  "  miner'sdbow,"  and  "  weaver 
!)ottom"  are  all  well-known  forms  of  bursitis.  Tuberculosis  affec 
the  bursa  usually  as  a  diffuse  granulomatous  affection  of  the  linii 
mem}>rane. 

Sarcoma,  endothelioma,  fibroma,  and  myxoma  of  a  bursa  have  ))et 
found,  but  none  of  these  are  common. 


THE  BONES 

It  is  worth  stating,  that  rigid  as  is  its  nature  and  apparently  fixc( 
bone  is  throughout  life  undergoing  a  steady  constant  process  of  absorj 
tion  and  reformation  according  to  the  needs  of  the  economy.  Thei 
is,  indeed,  no  more  excellent  exanii)le  of  the  economical  use  of  materii 
than  is  afforded  by  the  normal  structure  of  bon»-  particularly  the  lor 
bones.  Just  as  the  engineer  has  determined  tiiat  the  hollow  ste 
cylinder  is  capable  of  standing  greater  weight  and  greater  strain  than 
solid  column  formed  of  the  same  amount  of  material,  so  the  long  boiK 
are  formed  not  as  solid  masses  of  calcareous  matter,  but  as  cylinder 
and  what  is  more,  they  expand  at  their  extremities;  instead  of  l)eii 
solid  we  find  that  the  l)one  is  laid  down  as  a  lattice-work  of  "strut: 
whose  arrangement  is  finely  ailapted  to  bear  stresses  upon  the  bone 
particular  directions.  Now  these  stresses  may  vary  with  the  changii 
weight  of  the  individual  and  with  the  growth  of  the  different  parts,  ai 
as  a  consequence  we  find  that  these  "struts"  undergo  alteration  i 
adapt  them  to  the  altered  stress.  On  one  aspect  we  may  find  reniov 
of  the  bony  substance  through  the  agency  of  osteoclasts;  on  the  othi 
side  of  the  same  lamella  there  may  be  a  simultaneous  new  formation  ( 
layers  of  bone  through  the  agency  of  ilio  osteoblasts.  In  an  exagge 
ated  condition  we  may  find  these  simultaneous  prowsses  of  absorptic 
and  new  formation  occurring  in  diverse  pathological  disturbances. 

Abnormalities.—  In  true  dwarfism,  as  again  in  true  giantism,  tl 
bones  share  the  giiieral  abnormality  of  development  of  the  tissue 
There  are,  however,  other  dwarfs  in  whom  the  bony  development  is  w 
proportioned.  One  group,  for  exan  Ae,  exhibits  a  marked  shorttiiir 
of  the  limbs;  such  dwarfs  are  examples  of  chondrodystrophia  foetal 
(achondroplasia,  mieromelia).  There  has  been  much  deh-nte  as  \ 
the   imderlyiiig  process   in   this  condition,  but   the  disease  may  I 


J?^^    'JT^ 


^"p,«fcf  *;  '??>-.  :-^*---fjai»»4»i-- 


Till':  HOSES 


679 


ngiirded  as  a  fcctal  rachitis.  It  i  toiuui  that  the  periosteal  formation 
<it'  1m)iic  i)rocee(]s  in  a  normal  man  er,  hut  at  the  junctions  of  epiphyses 
and  diaphyses  the  chondriform  development  is  imperfect,  and  as  a 
result  the  bones  do  not  grow  ailequately  in  length.  A  similar  process, 
involving  the  skull,  is  to  he  seen  in  those  hones  which  are  of  chondri- 
form c.igin,  that  is,  in  the  bones  of  the  '  -se.  As  a  result  of  their 
imperfect  development  the  base  becomes  ...<».  kedly  shortened  and  the 
l)ri(lge  of  the  nose  sunken  in;  and  as  the  nasal  bones  themselves  also 
arc  of  chondriform  origin  the  nose  is  short,  flattened,  and  of  negroid 
type. 

A  somewhat  similar  arrest  of  development  of  bony  growth  is  seen  in 
cretins  (qretinism),  there  assoeiatinl  with  congenital  inadequacy  of  the 
tliyroid;  the  bony  skeleton  in  this  condition  shows  more  particularly 
a  sliortening  of  the  limbs,  something  of  the  type  seen  in  chondrodys- 
tn.phia  but  not  so  extreme,  while  there  is  the  same  indication  of  arrested 
<l(\ilopment  of  the  chondriform  bone  formation  of  the  skull  base  pre- 
Miitcd  by  the  nose.  With  this,  however,  there  is  more  marked  general 
arrest  of  mental  and  sexual  development  than  is  presented  in  chondro- 
ilvstrophia. 

^'tt  another  type  of  congenital  bone  disease  is  seen  in  what  is  termed 
osteogenesis  imperfecta,  although  many  other  names  have  been  given, 
a--  fragilitas ossium,  osteopsathyrosis,  or  myeloplastic  malacia.  In  this  con- 
(litidn  during  early  life  and,  indeed,  during  intra-uterine  life  the  bones 
>lin\\  an  abnormal  liability  to  fracture.  In  a  case  in  our  collection, 
reported  by  Klotz,  the  body  of  the  newly  born  infant  showed  over  a 
Innidrcd  such  fractures.  Associated  with  this  there  is  marked  deformity 
iind  sliortening  of  individual  bones  and  of  the  skeleton  in  general. 
Tills  is,  strictly  speaking,  more  closely  allied  to  rickets  than  is  chondro- 
il.ystrophia;  there  is,  namely,  abundant  preparation  for  the  formation 
of  lioiie,  in  the  shape  of  well-developed  cartilage  formation,  only  there 
i-  a  failure  both  in  the  periosteal  and  chondriform  metamorphosis 
iiitii  true  bony  tissue.  Even  in  the  shafts,  the  periosteum  may  give 
ori-iii  to  fibrous  tissue  rather  than  bony  lamellae.  This  defective 
liiriiiation  may  be  so  extreme  that  large  areas  of  the  calvarium  may 
ri main  purely  membranous. 

Circulatory  Disturbance.— The  very  rigidity  of  the  channels  within 
ilif  lione  substance  prevents  extreme  alterations  in  the  blood  supply. 
I  ill'  iieriostcuni,  however,  is  liable  to  exhibit  more  pronounced  changes, 
active  hyperemia,  passive  hyperemia,  etc.  More  important,  there  may 
I'l  ' Atcnsive  periosteal  hemorrhages,  either  traumatic  or  as  a  result  of 
•  liMaM..  Closely  allied  to  the  traumatic  mu.st  be  mentioned  a  most 
^inkiiij,'  form  of  periosteal  hemorrhage,  viz.,  the  cephalhematoma  of 
lit'  newborn.  Here  as  a  consequence  of  unduly  prolonged  presentation 
"I  'ill  liead  in  the  cervical  portion  of  the  uterus,  and  of  the  great  com- 
|ir.  ion  exerted  upon  the  body  of  the  infant  by  the  contracting  uterus, 
tlir  .  xtrenie  oo„gcstion  of  the  vessels  of  the  calvarium  leads  to  rupture 

■'     same  as  they  pass  into  the  overlying  pericranium,  with  hemor- 


t.i- 


\\v 


I3^-    r-rfJ^JCK;\fcili 


080 


THE  MOTOR  AND  TEGVMENTARY  SYSTEMS 


W^ 


rhage  between  the  tvo  layers,  and  an  accumulation  of  blood  the  ; 
of  half  an  orange  i>-ay  result.  This  hematoma  may  undergo  abs( 
tion,  but  if  the  process  of  removal  is  slow,  a  ring  of  bony  growth  n 
occur  at  the  periphery. 

Infarct. — The  predisposition  shown  by  young  children  to  osteom 
litis  originating  at  the  ends  of  the  long  bones  is  usually  ascribed 
the  active  vascularity  with  new  vessel  formation  presenting  itself  in 
neighborhood  of  the  epiphyseal  line,  the  new  vessels  here  becom 
the  seats  of  bacterial  emboli.  We  have  stated  elsewhere  that 
doubt  whether  such  emboli  are  truly  primary;  rather  we  imag 
that  individual  bacteria  arrested  by  the  endothelial  cells  multi 
and  set  up  a  focus  of  inflammation  with  thrombosis.  Whet 
actual  infarcts  occur  is  a  matter  of  controversy.  The  appearance  si 
in  many  cases  of  tubercult)sis  of  the  ends  of  the  long  bones  stron 
suggests  infarct  formation;  wedge-like  areas  of  necrotic  bone  may 
detected  having  their  bases  immediately  beneath  the  cartilage,  but  h 
it  may  well  be  that  there  is  not  primary  embolism  but  obliteration 
the  nutrient  artery  in  consequence  of  perivascu'ar  tubercle  format 
and  the  associated  endarteritic  changes.  Extensive  i  ecrosis  may  oc 
where,  either  through  trauma  or  through  accumulatior.  of  inflammat( 
products,  or  of  blood,  the  periosteum  becomes  separated  from  theund 
lying  bone  and  the  nutrition  of  the  latter  cut  of!'. 

Tnflammation. — According  as  the  inflammation  involves  the  peri 
teum  and  the  surfaces  of  the  bone,  or  the  substance  of  the  bone  and  i 
medullary  cavities,  so  do  we  distinguish  between  a  periostitis,  an  ost 
myelitis  or,  inasmuch  as  one  process,  if  severe,  inevitably  leads  to  i 
other,  a  general  osteitis  or  panostitis. 

The  study  of  these  conditions  is  complicated  by  the  fact  that  when 
an  infective  agent,  acting  intensely,  leads  ti,  necrosis  and  absorpti 
of  the  bone  substance,  in  the  areas  of  surrounding  hyperemia  then 
set  up  coincidently  a  productive  i)rocess  leading  in  the  deeper  parts 
the  bone  to  increased  thickness  of  the  lamellre  and  greater  density 
the  tissue,  and  on  the  surface  to  the  formation  of  new  bone  layers 
of  osteophytes,  irregular  processes  of  new  bone.  In  extreme  ca 
the  intensity  of  the  inflammatory  j)rof'ess  and  the  presence  of  tensi 
may  lead  to  the  necrosis  of  relatively  large  masses  of  bone,  wlii 
undergo  a  \ery  slow  process  of  absorption  while  simultaneously  t 
periosteum  gives  origin  to  new  bony  layers.  As  a  result  we  oi)tair 
sequestrum  surrounded  by  an  involucrum,  with  associated  thickeiii 
and  deformity.  Usually  in  these  cases  the  purulent  fluid  surroundi 
the  sequestrum  makes  its  way  along  the  line  of  least  resistance,  tliroii 
some  area  of  weakened  periosteum,  into  the  subcutaneous  tissues  a 
so  to  the  surface,  giving  rise  to  one  or  more  sinuses. 

Periostitis.^ — Acute  periostitis  may  be  of  two  forms,  simple  and  sii 
purative.  The  former  shows  itself  in  non-infective  traumatic  int< 
tiuns  and  in  illfeetion^s  of  low  virukmc,  and  is  characterized  by  a  ivM 
acute  course  with  infiltration  and  subsequent  thickening  of  tlu  i)e 


•!^KElSJX^:•%  =,'. . 


w^m 


OSTEOMyEUTIS 


681 


(i>rt>um,  stimulation  of  the  gonetic  layer  to  active  Ixme  production 
ri  lilting  in  a  local  increased  jjroduction  of  hone  in  the  form  of  osteo- 
pli.xtes  or  nodular  thickening.  Suppurative  periostitis  is  much  more 
.Kiite,  and  involves  a  larger  area  and  shows  itself  as  an  accui..ulation 
lit'  i)us  cells  within  the  periosteum  and  then  between  the  periosteum  and 
the  hone.  This  accumulation  of  pus  tends  to  extend  around  the  shaft 
of  the  bone  laterally  in  all  directions,  inasmuch  as  the  density  of  both 
•MTiosteum  and  bone  prevents  extension  either  outward  or  inward. 
Thtre  is  thus  great  tendency  for  the  nutrition  of  the  bone  through  the 
periosteum  to  be  cut  off,  as  also  for  the  process  to  extend  to  the  joint 
setting  uj)  a  suppurative  arthritis.  With  the  continuance  of  the  dis- 
ease, the  periosteum  at  t)iie  or  other  point  may  undergo  atrophy  and 
erosion,  the  pus  thus  extending  into  the  surrounding  tissues  and  setting 
lip  a  i)eriosteal  supi)urative  process.  So  also  in  some  cases  the  i)rocess 
extends  along  the  vessels  into  the  marrow,  inducing  a  panosteitis.  Such 
suppurative  periostitis  may  be  brought  about  in  two  ways,  either  as 
the  result  of  an  infective  traumatism  or,  as  happens  not  infrequently 
ill  voinig  children,  as  a  hematogenous  or  cryptogenetic  process.  The 
or^;iiiiisnis  associated  with  the  process  are  most  frequently  the  pyogenic 
(oeei,  and  such  bacilli  as  B.  coli  and  B.  typhosus.  The  latter  is  espe- 
eially  ai)t  to  set  up  a  somewhat  restricted  and  localized  suppurative 
periostitis,  sometimes  showing  itself  long  after  the  acute  infection  has 
passed.  In  the  younp,  there  is  a  peculiar  liability  for  this  suppurative 
form  ()f  disease  to  extend  along  the  epiphyseal  lines  and  lead  to  separa- 
tum of  the  epiphysis  from  the  shaft  of  the  bone. 

Osteomyelitis.— In  this  condition  the  primary  infection  occurs  in 
tlu  marrow  of  the  bones,  and  may  be  set  up  by  the  same  organisms 
as  iiuliur  in  other  cases  periostitis.  Like  periostitis,  the  condition  is 
nin^t  eonnnon  in  the  young  and  during  adolescence,  while  the  long 
li'mes  arc  those  most  frequently  affected.  As  already  indicated,  not 
iiilrecpiently  the  disease  begins  as  an  infective  epiphysitis. 

The  ordinary  course  of  infection  is  modified  in  the  case  of  the  bony 
Mil.MaiKc  by  the  unyielding  nature  of  the  framework;  the  congested 
\<  -els  cannot  throw  out  much  exudate  or,  more  correctly,  the  exudate 
ami  infiltration  of  leukocytes  react  upon  the  vessels  themselves  favoring 
tiiiuinl.osis  and  the  rapid  production  of  relatively  large  areas  of  necrosis. 
llm>  caries  or  necrotic  softening  with  absorption  and  more  extensive 
iierroses  of  bony  tissue  is  a  common  accompaniment.  We  have  alreadv 
reterred  to  the  results  of  these  processes  in  the  production  of  sequestra; 
^".  airaiii,  the  inflammation  is  very  apt  to  extend  to  the  periosteum  in- 
'lii-  ing  suppurative  periostitis,  periosteal  iierforation  and  the  formation 
"I  h^tulre  The  process,  if  very  ai  ite,  gives  rise  to  a  generalized  bac- 
t' '  i.  una  or  pyemia  resulting  in  deati  :  if  less  acute,  is  followed  by  various 
siauxs  of  reactive  development  of  new  bone,  although  often  f-  -n  the 
fii'  o>ed  nature  ot  the  foci  of  suppuration  the  acute  stage  pa&^v.  on  to 
1-  nironic  or  latent  form  of  osteomyelitis,  with  tendency  toward  acute 


e\;i 


■  rl)atioiu  from  time  to  time,  over,  it  may  be,  years. 


i 


a 


»    a  1 

r  J 

I 
r 

iff 

I 


if 


:•**■/.??#!& 


'■•^^mpmKsrw'v 


682 


THE  MOTOR  AND  TEGVMESTARY  SYSTEMS 


M  1 


Mn 


Chrome  Periostitis.-  Various  forms  are  (lescrihed.  As  already  ii 
cated,  continued  mild  inflammation  of  the  periosteum  leads  to  b 
overgrowth,  and  the  formation  of  osteophytes— periostitis  ossiflc; 
1  he  periosteal  overgrowth  of  hone  after  fractures  is  of  this  nati 
so,  also,  the  bony  overgrowths  through  irritation  induced  by  neighf 
ing  tumors  or  inflammation  of  overlying  structures,  as  is  well  she 
111  the  nodular  o\ergrowth  of  the  tibia  under  a  chronic  ulcer  To 
c()mmonest  form  of  chronic  periostitis,  viz.,  the  syphilitic,  refere 
will  be  made  later.  A  remarkable  type  of  periosteal  inflammati 
the  penostitis  albuminosa,  has  been  described  by  Oilier  in  which  a  th 
serous  fluid  containing  albumin,  and  a  few  pus  corpuscles  and  so 
hbriii,  collect:s  between  the  periosteum  and  bone;  it  appears  to  be 
mildly  infective  origin,  and  differs  merely  in  degree  from  the  m^ 
acute  suppurative  periostitis. 

Chronic  OsteomyeUtis.— According  to  the  virulence  or  concentrati 
of  the  infective  agents,  so  do  we  find  two  processes  manifesting  the 
selves  in  cases  of  long-continued  inflammation  of  the  bone  substan 
VIZ.,  rarefaction,  or  osteoporosis  and  condensation,  or  sclerosis.  Rarefyi 
osteitis  is  evidenced  by  the  progressive  absorption  of  the  bony  lamell 
Ihe  marrow  becomes  increasingly  vascular,  and  through  increas 
osteoclastic  activity  the  compact  bony  tissue  undergoes  reducti 
until  It  assumes  a  loose  spongy  appearance.  According  to  Ribb« 
and  others,  m  these  inflammatory  processes  the  i)resence  of  osteocla* 
IS  not  essential  but  ordinary  leukocytes  possess  the  capacity  of  causii 
absorption  of  the  bone,  as  clearly  happens  when  the  bone  has  alrea( 
uiKlergone  necrosis,  as  in  a  sequestrum. 

Condensing  osteitis  occurs,  as  already-  st.jted,  where  the  irritation  is  n 
so  intense.  One  of  two  events  may  occur;  either  there  is  evidence 
increased  osteoblastic  activity  so  that  the  lamella;  undergo  progress!^ 
thickening  and  the  marro.x  sjiaces  become  correspondingly  reduce, 
or  the  marrow  first  becomes  less  cellular,  shows  an  increased  fihrosi 
and  the  cells  of  this  fibroid  tissue  undergo  metaplasia,  becoming  boi 
corpuscles.  In  this  way,  save  for  a  small  space  around  the  ceiitr 
vf>ssels,  the  whole  of  the  marrow  may  become  converted  into  deii: 
hone.  If  at  the  same  time  there  is  progressive  periosteal  new  develo] 
ment  the  shaft  may  become  thickened  to  twice  its  normal  diametc 
aiHJ  the  central  marrow  may  be  completely  replaced  by  solid  boiK 
It  IS  this  secondarily  formed  compact  bone  which,  from  its  extreiu 
density  and  likeness  to  ivory,  has  been  described  as  ebumated  bone. 

We  shall  discuss  the  so-called  osteitis  deformans  among  the  regressiv 
changes. 

Specific  Inflammations.— The  bone  is  peculiarly  liable  to  be  inftcte( 
in  both  tuberculosis  and  syphilis,  and  to  present  characteristic  mo-lifi 
cations. 

Tuberculosis.— Tuberculosis  may  show  it.self  either  as  (1)  of  primarj 
periosteal  origin,  or  as  (2)  ,i  form  ..f  specific  osteomyelitis,  or  (3)  i 
generalized  miliary  tuberculosis.     The  last  is  relatively  unimportant 


■wmi^' 


BO\E  TUBERCULOSIS 


683 


m..s„n,cl  a-s  death  occurs  before  any  ^-rave  change  has  er.sued  in  the 
1.O..0S.  IV-nostitis,  als:.,  .s  apparently  not  of  first  importance-  it  s 
>rrn  particularly  u,  the  rihs.  By  far  the  most  importa,  ta 
tuberculous  osteomyelitis  Certain  bones  are  particularly  apt  o  be 
=iitK'  «1,  notably  the  en.ls  of  the  long  bones,  the  fen,ur  and  tl  e  t^b b 
>HMi  the  vertebrae.  Less  frequently  the  calvarium  and  the  pl^^alants' 
.nay  be  nuolved.     Tuberculosis  of  the  spine  and  the  ZgZZt 

l.-rp  (xtent,  to  the  function  of  the  parts  cent  -ned.  namely,  that  the 
wHght-beanng  of  the  body  is  veste.1  in  them;  thus  the  tuberculous 
.hsease  is  assisted  by  pressure  at  all  times  during  which  the  upSt 

i.v  IR  pressure,  fh is  osteoniyehtic  process  in  the  long  bones  originates 
«.  I.  great  rarity  in  the  sliaft,  save  in  connection  with  the  phalSes  S 
I  ..Idren  spma  ventosa)  but  almost  always  in  the  epiphyseal  e S  and 
tins  ,n  cnildren  and  adolescents.  The  process  begi  ,s  by  the  forma- 
t...n  of  a  conglomerate  tuberculoma,  with  surrounding  <leve  opmenH 
j;n.nulat.on    issue  in  the  medullary  spaces  an.l  absorption  ofX  boi  e 

m.i     shou   little  tendency  to  caseation  and  granulation  tissue  for- 

m.m  may  predominate  or,  more  frequently,'the  mass  of  tubercles 

>...  es  while  simultancusly  new  tubercles  form  in  the  surrouiiS 

"  ■-Inllary  spaces  with,  as  a  result,  a  progressive  ami  sprea.ling  ^^  eou! 

.n  Kc,  and  accompanying  .lestruction  and  rarefaction   of  the   Se 

y..     We  have  a  ready  pointed  out  how  economically  the  normal  bZ 

^ul.>tance  is  laid  ,lown  in  relation  to  the  strain  it  is  called  unoio 

Ij-r,  and.  therefore,  if  there  be  any  considerable  area  of  rare  acS  "nd 

■>tnu.t,on  without  correspomling  overgrowth  in  the  neigh borhr-   the 

n  otal.e  result  is  that  the  bone  gives  way  and  becomes  disto  tl^ 

1    IMPt  un  oh ed.     At  this  process  advances,  it  is  apt  to  extend  to  the 
rnlaguHuis  joint  surface  and  with  erosion  of  thJ  cartilage  thrmS 

rtiir,t.>  ,s  set   up.     A  similar  osteomyelitis  involving  the  vertebre 
r;;;:;'?;"  ^'^*\-'f -"--f  the  bodies,  often  as  scattercUo  ^^'l  S^ 
1  ■>  /nlarge  by  formation  of  new  tubercles  at  their  peri,  her  t's 
I  to  tuse  aiHl  give  origin  to  large  areas  of  caseation  and  caHe      he 

i  i.m  "w."'  'X  "''"  ''''^''  '^'  IH-riosteum  and  interferes  wih 

rm.rn.     ^Vhen  the  process  extends  to  the  intervertebral  disk  it 

—^  a  rapid  destruction  of  the  same  with  extension  of  the  tuberculous 

li.     t  ,      n  •   I    f''l  '''™'"''  compressed  under  the  weigh:  to 

tIH^  are  subjected  and  kyphosis  or  angular  backward  curvature 

,n         ,  Jr  ''''  ^  ''''"'*  °*  *'"'  compressing  force  or  from  the 

'    1-ratively  thin  periosteum  covering  the  vertebral  bodies     L  is 

P'  Huunced  tendency  for  th  >  softened  caseous  matter  formed  Sin 

tin  ^.rtebral  body  to  escape  into  the  immediately  overlying  tfs  u  s" 


-M^^iSf 


684 


THE  MOTOR  AM)  TKCVMKSTMiY  SYSTEMS 


|. 


in  wliicli  it  may  travel  ^reat  distances  by  mifxiM'ctfd  courses,  indue 
wliat  is  called  a  cold  abscess.  The  abundant  contents  of  such  are 
constituted  of  true  \ms  hut  of  diluted  cheesy  matter  with  a  small  |i 
portion  of  h'ukocytes  an<l  lymphocytes  unless  a  secondary  infect 
has  occurred,  when  there  is  a  greater  predominance  of  leukocx 
elements.  The  term  rolil  doubtless  refers  to  the  lack  of  surround 
inflammatory  numifestations,  such  as  the  active  hyperemia  of  the  si 
A  cold  abscess  is  usually  lined  l)y  a  laytT  of  necrosiuf^  or  caseat 
tuberculous  tissue.  Similar  periosteal  extension  of  the  process  may  sh 
itself  where  the  upper  end  of  the  femur  is  involved  ("hip-joint  diseasi 
or  when  the  knee  is  affected  ("white  swelling"). 

Syphilis.  The  bones  are  almost  always  involved  to  a  greater  or  I 
extent  in  cases  of  congenital  syphilis  and  are  frequently  the  seat 
lesions  in  the  ac(juired  disease.  .\s  with  other  organs  we  can  distingu 
diffuse  and  circumscribed  lesions.  The  circumscribed  lesions  or  guini 
may  develop  as  a  com])aratively  late  manifestation  and  then  either 
the  periosteum  or  in  the  medulla.  They  arc  slowly  progressive  ii 
cause  little  destruction  as  compared  with  the  tuberculo  is;  rather, 
general,  they  induce  a  surrounding,  almost  ctmipcnsatory  sclerosis,  ai 
in  the  case  of  the  periosteum,  active  new  bone  formation,  the  res 
of  which  is,  very  frc(|ucntly,  a  localized  nodular  thickening  and  ov 
growth  in  their  immediate  neighborhood.  Hut  more  particularly  in  i 
calvarium,  the  obliteration  of  the  vessels  leads  to  necrosis  and  extciis 
localized  destruction  (caries).  Tnlike  the  tubercle  bacillus  the  spirocli 
has  no  special  seat  of  election  in  the  bones;  the  gummas  may  be  ( 
fu!-ely  scattered  through  both  the  diapli^sis  and  the  epiphyseal  regii 

The  diffuse  form  of  syi)hilis  is  charact»'ri/.cd  by  increased  bone  j) 
•luction  (periosteal)  and  sclerosis,  so  that  the  long  bones,  for  e\ani| 
become  greatly  thickened  and  condensed.  With  this,  there  is  a  liabii 
to  the  formation  of  exostoses,  which  may  be  seen  in  the  long  bones  1 
more  particularly  on  the  imicr  aspect  of  the  calvarium.  As  a  resi 
the  vault  of  the  skull  is  found  greatly  thickened,  so  dense  as  to 
sawn  with  difficulty,  and  on  its  inner  asjM'ct  there  may  be  a  niassi 
de\elopjnent  of  clos»'  set  nodular  osteophytes. 

The  characteristic  disturbance  of  congenital  syphilis  is  what  may 
termed  osteochondritis,  affecting  tlie  layer  between  epiphysis  ami  d 
physis  of  the  long  bones  and  the  osteochondral  junction  of  the  ril 
We  find,  either  that  there  is  an  undue  formation  of  the  cartilage,  wlii 
undergoes  calcification  without  proper  bone  formation,  or  this  calcificnti 
of  the  cartilage  is  accompanied  by  an  excessive  granulation  tissue  sendi 
processes  into  the  ejjiphysis.  In  cither  case  the  fine  line  of  demarcati 
between  epiphysis  and  diaphysis  is  replaced  by  a  broad  yellowi 
band,  often  irregular,  which  consists  of  cartilage  which  has  not  f,'ii 
on  to  proper  bone  formation.  As  a  result  there  is  to  be  obser\t'(l 
distinct  liability  to  separation  of  the  epiphysis  under  very  slight  prov 
cation.  The  conditinn  shows  itself  in  the  first  few  weeks  of  life  mi 
recovery  may  follow.     At  a  later  period  in  these  congenital  cases,  tiit 


s 

scs,  imiuciiig 
sucli  are  not 
a  small  |)r(i- 
iry  infection 
if  leukocytic 
surrounding 
I  of  the  skin, 
or  caseating 
'ssuiay  show 
tint  disease") 

■eater  or  k'ss 
the  seat  of 
u  distinguish 
IS  or  gummas 
len  either  in 
gressive  and 
s;  rather,  in 
derosis,  and, 
n,  the  result 
ig  and  over- 
ularly  in  the 
nd  extensive 
he  spirochete 
may  be  dif- 
yseal  region. 
:'d  bone  \m)- 
for  example, 
is  a  liability 
ig  bones  but 
As  a  result, 
ise  as  to  he 
»e  a  massive 

rhat  ma\  be 
sis  an<l  dia- 

of  the  ribs, 
iilage,  which 

ealcificiition 
issue  sending 
demarcation 
id  yellowish 
as  not  gone 
:  obser\<'d  a 
(light  ])rovo- 
j  of  life  ;iiid 

cases,  tiicre 


77/A'  liOXKS 


OS.-) 


may  develop  a  syi)liilitic  periostitis  of  the  same  order  as  that  .seen 
ill  the  acquired  diseast-.  Gummas  are  rarely  seen  in  the  newborn  but 
-non  after  birth  the  gummatous  process  affecting  the  septum  nasi 
limy  lead  t-  its  destruction  with  the  development  of  a  "saddle-back" 
iio-e.  This  proct.s  may  lead  in  addition  to  jxTforatiou  of  the  hard 
piilate  or  be  accompanied  by  atrophic  rhinitis  and  ozena. 

Other  Infective  Granulomas.  ( )f  the  other  infective  granulomas, 
iitttiition  may  })(•  called  to  the  involvement  of  the  bones,  especially 
\hv  lower  jaw,  in  a  j)rimary  actinomycotic  process.  Unlike  what  is  seeli 
ill  (attic,  the  condition  in  man  is  rarely  Mrimary  in  the  bone  itself.  In 
( (iiincction  with  leprosy  of  the  anesthetic  variety  it  must  be  rec-alled  that 
the  [ihalanges  are  apt  to  undergo  a  rarefying  osteitis  an<l  absorption. 
Iliiibitz  considers  this  to  be  due  to  a  tro|)lu.neurosis. 

Regressive  Changes.— Atrophy.  -We  have  already  referred  to  senile 
(h:iiigcs  in  the  bone  marrow;  in  athlition,  with  old  age,  the  bony  sub- 
-t.iiice  undergoes  progressive  absor|)tion  and  regression  so  that  the 
Imiims  become  light  and  very  brittle,  .-^uch  senile  atrophy  is  esi)ecially 
Mill  in  the  fiat  bones,  including  the  lower  j.iw,  but  affects  also  the  long 
liniMS  and  exhibits  a  combination  of  two  processes,  viz.,  (1)  superficial 
:iliM,r|)tion,  the  so-called  concentric  atrophy,  whereby  the  diameter  under- 
i;h(s  rcdnction  and  (2)  osteoporosis  or  Haversian  atrophy  or  lacunar 
r(-(irptiou,  the  Haversian  canal  becoming  distiiutly  enlarged  by 
iih^orption  of  the  superficial  layers  of  the  lamellie.  The  abo\e-meii- 
tiniKcl  atrophy  seen  in  anesthetic  leprosy  is  an  extreme  example  of 
this  order  of  (hange;  cU)sely  allied  is  the  atroi)hic  change  in  bones, 
ni'iiiiiitercd  in  syringomyelia  and  tabes  dorsalis.  Other  examples 
iirc  Mfi  in  disuse  atrophy,  and  the  atrophy  and  absorption  secondary 
•>  prosurc  (though  here  also  there  is  inHanmiatory  absorpti(m  of  the 
ti-iic  whose  nutrition  has  been  reduced). 

Halisteresis.- Such  simple  atrophy  m  r  be  distinguished  from 
IwlMcresis  in  which  the  absorption  of  tin  bone  is  preceded  by  solution 
jiiiil  iii)sorption  of  the  bone  salts.  This  latter  process  is  dominant 
111  (t Ttain  remarkable  disorders,  notably  in  osteomalacia  and  in  many 
<:iM  ^  (,r  so-called  osteitis  deformans,  between  which  disorders  there  are 
iii:ii!.\   points  of  relationship. 

Osteomalacia  is  a  condition  most  frequently  described  in  females  and 
tlirii  111  association  with  pregnancy  or  lactatictn,  but  it  may  show  itself 
iiiMi  III  adults  either  male  or  female.  It  is  apt  to  affect  the  whole  bonv 
triiin.uork  and  may  show  itself  first  in  particular  orders  of  bones. 
.\nt;iMy  in  tlic  female,  the  pelvis  is  apt  first  to  show  disturbance,  and, 
tlin  i-li  the  loss  of  bone  salts  and  softening,  there  may  be  developed 
^triL  iiir  deformity,  the  acetabnla  being  pushed  upward  by  the  weight 
"'  '1  '  body,  the  blades  of  the  ilia  pushed  outward  so  as  to  become 
iii'T.  Iiorizontal,  and  the  pelvic  outlet  correspondingly  diminished. 
*\  iiii  this  there  may  als(»  be  great  softeninir  of  the  bodi<-s  of  the  vertebra' 
»itl,  ii.r.losis,  kyphosis,  and  scoliosis,  and  the  h>ng  bones  may  be  found 
-"      ncned  that  they  can  be  easily  cut  with  a  knife.     The  process 


i 


3" 

5 

■  *  ^ 

ii 

1 


1 


08G 


THE  MOTOR  AM)  TKdlMHSTAIiY  SYSTEMS 


'I';f 


niiiy  jjo  on  until  tlu-n-  is  practifally  cniiijili-te  abst-iKr  of  hoiw  salt- 
imlividiial  Ixnics,  hut  in  frcncral,  iiUn\ff  with  tlie  aI)S()ri)tion,  thtTo 
evitlcnces  of  attempted  achiptatioii  or  reneneration  so  that,  for  exani] 
ill  a  Ion);  hone  which  lias  underKoiie  <leforniity,  while  on  the  conves 
of  the  curve  the  hone  is  rarefied,  there  is  thiekeniiig  alonjr  the  eoneavi 
only  lien-  the  new  hone  formation  is  imperfect.  Microscopicf 
the  hone  presents  a  very  characteristic  appearance;  the  Havers 
canals  and  the  medullary  .paces  are  cnlarned  and  ccmiparatively  i 
poverished  in  cell  contents;  the  lamelliT'  may  he  wholly  devoid  of  h( 
salts,  or  more  frequently  the  central  layers  still  contain  these  salts  i 
are  .siirntunded  on  either  side  hy  layers  of  somewhat  hyaline  oste 
suhstaiice,  devoid  of  salts,  hut  taking;  on  a  dilVerential  color  with  vari( 
stains,  heinj;  esjiecially  strongly  stained  liy  carmine.  The  process  n 
lie  progressive  or  may  he  arrested  and  once  more  the  lamelhe  att 
their  due  amount  of  calcareous  material.  Accompanying  the  devel 
ment  of  the  process  there  is  a  marked  increase  in  the  excretion  of  ( 
careous  salts  in  the  urine,  the  milk,  and  even  the  feces.  As  to  the  ori 
of  the  disease,  little  is  known;  its  fre(|ueiit  association  with  gestat 
suggests  that  here  we  may  deal  with  some  disturhance  of  the  ovai 
as  organs'  of  internal  secretion. 

Osteitis  Deformans  {Piujrt'n  ^^<sr(use  of  the  Roiir). — This  is  a  ji 
gressive  condition  alVccting  tlv  iiy  skeleton,  most  often  of  elde 
individuals,  not  necessarily  ahecting  all  the  hones  hut  telling  rii 
particularly  ujion  the  long  hemes  (iiotahly  the  tihia),the  skull,  and 
vertehriu.  Cases  are  on  record  in  which  a  single  tihia  or  a  single  fen 
has  heen  involved;  the  afl'ected  hones  show  progressive  irregular  tin 
eiiing  comhined  with  distortion  and  exaggeration  of  the  normal  cur 
tare.  1  nere  appear  to  be  two  if  not  three  stages  in  the  process  affect 
the  hone.  First,  there  is  halisteresis  re.semhling  that  seen  in  ost 
nialaeia  lui*  followed  or  accompanied  hy  a  much  more  pronoiiiu 
periosteal  and  even  medullary  new  growth  of  osteoid  tissue.  T 
new  tissue  does  not  gain  proper  calcification,  hut  on  the  contrarv 
apt  in  turn  to  hecome  the  seat  of  absorption  with  enlargement  of 
niedullar\  and  Haversian  canals.  Associated  with  this,  as  a  tli 
stage,  the  medulla  undergoes  characteristic  and  difi'use  change, 
place  of  being  fatty  or  abundantly  cellular,  it  becomes  fibroid.  \ 
Recklinghausen  regarded  this  change  as  of  an  inflammatory  natii 
and  spoke  of  the  condition  as  osteomyelitis  fibrosa.  We  can  find 
evidence  of  this  inflammatory  stage  and  regard  the  process  as  me 
plastic.  This  "  Fa-icrniark,"  or  fibroid  medulla,  is  apt  to  show  areas 
degeneration  with  cyst  formation,  but  in  a  certain  proportion  of  ca 
exhibits  a  further  diffuse  metaplastic  change,  becoming  abundan 
cellular  with  a  tendency  to  the  formation  of  new  osteoid  lamella'  c 
what  might  he  termed  a  blastomatoid  formation  of  new  bone-produc 
tissue,  which,  in  its  turn,  may  again  give  place  to  infiltrative  locali; 
growth  of  sarcomatous  nature' 

'  This  occurred  in  a  case  very  thuroughly  studicU  in  our  own  laboratory  this  year  by  the 
Dr.  Elsie  B.  Wilkic. 


wmn 


mpvm 


RICKETS 


687 


year  by  tin'  l»"; 


(lusf  upon  10  ptT  cent,  of  rt-conled  cases  oxhiliit  tliis  eventual  local 
iiKilijiiiancy.  With  this  general  osteoid  chunne  and  softening  of  the 
Ihiiic  there  may  be  "xtraoniinary  deformities  priMluced.  As  ti>  the 
causation  of  this  diseast*  notiiing  definite  is  known,  hut  the  diffuse 
X\\w  of  the  change,  the  known  association  hetweeii  *he  pituitary,  the 
pitnithyroids,  and  the  calcium  metaholism  of  the  hooy,  lead  us  to  tliB 
litTit'f  that  lu-re  we  deal  with  another  of  the  disturbances  associated 
witli  want  of  balance  l)etween  the  organs  of  internal  secretion.  A  few 
(UMs  have  been  recorded  in  which  lesions  of  the  i)ituitary  and  thyroid 
liavc  been  associate<l  with  the  condition. 

Rickets  (Rachitis). — This  is  a  disease  affecting  the  skt-leton  in  general 
ami  manifesting  itself  after  birth,  mo^t  often  in  the  first  and  second 
,\  ( ars,  although  it  may  continue  as  an  active  process  into  early  childho<Hl. 
Its  ctlVcts  are  shown  most  characteristically  in  coimection  .vith  the 
Iduj;  l)onts,  the  ribs  and  costochondral  junctions,  and  the  skull.  The 
(li)iiiinating  feature  of  the  disease  is  an  excessive  preparation  for  the 
loniiation  of  cartilaginous  bone  followed  l)y  defective  deposit  of  bony 
sali^  whether  in  chondrif(»rm  or  membraniform  l)one.  This  leads 
til  the  development  of  bones  which  are  imperfectly  rigid  and  liable 
ti)  txliibit  irregular  and  excessive  curvature  with  deformity,  along 
with  "green-stick"  or  partial  fractures.  The  condition,  however,  is  not 
ptTriuuicnt  and  the  deformed  bones  eventually  gain  a  normal  or  more 
than  normal  deposit  of  calcareous  .salts,  although  the  <leformity  may 
l)tT>i>t  through  life.  The  process  may  involve  the  spinal  column 
Itinliiig  to  curvature,  and  through  the  soft  condition  of  the  ribs  tht-y 
>  ii  1.1  to  the  forces  acting  up(>ii  them,  .so  that  the  clu'st  1h'(  omes  flattened 
in  till-  anterolateral  regions  and  the  sternum  forced  forward,  causing 
wliat  is  known  as  "pigeon-breast."  The  rachitic  "rosary"'  is  a  swelling 
nf  -luccssive  regitms  of  junction  of  ribs  with  sternal  cartilages;  while 
this  can  be  felt  from  without  during  life,  it  is  most  j)ro!iounced  on 
the  inner  aspect.  The  joints  of  the  limbs  ap{)ear  enlarged  relative 
to  the  shafts  of  the  bones.  The  forehead  may  take  on  a  curiously 
><|M;irc  appearance,  due  to  what  is  known  as  cranio-tabes,  with  thiiming 
nf  llic  cranial  bones,  most  marke<l  in  the  parietal  and  occipital  bones, 
anil  I  here  may  appear  hyperplastic  "bosses"  of  the  frontal  and  parietal 
lioiit  -.  With  this  there  is  delayed  union  of  the  sutures,  so  tliat  the 
aiiti  riur  f(tntanelle  may  remain  open  imtil  the  beginning  of  the  fifth 
year  1  )cntition  is  late  and  the  teeth  fall  an  easy  prey  to  carious  change. 
As  to  the  causation  of  rickets,  little  is  known  with  any  precision. 
It  i-  ni.t  of  sy|)hilitic  origin,  although  it  may  occur  in  the  subjects  of 
iLM  iiital  syphilis;  it  is  most  often  found  in  city  children;  lack  of  fresh 
-nnlight,  unsanitary  surroundings  and  deficient  nutrition  are 
l>rc(lisposing  factors,  although  of  two  children  subjected  alike 
-(•  influences  one  may  become  rickety,  the  other  not.  Recently 
irtro,  confirmed  by  other  Italian  patliologists,  has  isolated  what 
inis  as  the  si)ecific  organism  inducing  the  condition.  The  time 
t  come  to  state  with  certainty  that  this  is  an  infective  disease. 


ciiiii: 
air  ,i!!i 

stHiii 
to  l!; 
Mo:; 


|i 


FRP 


^V 


fiSK 


TIIH  MOTOR  WD  TtJn  MKSrARY  SYSTEMS 


If  Wf  «'\aiiiiii«'  tlu-  «i)ii>liys«'al  «'inl  nf  «>in'  cf  tin-  luii);  boiH's,  tln>  I 
of  ciirtiliin"'  iMtwt'CM  I'pipliysis  anil  diaplivsis  is  found  jtrtatly  tjiickn 
anil  fin>?«T-liki'  priwcsM-s  of  nt-w  cnrtilap-  »'Xt«Miil  iU'«'ply  into 
marrow,  nivinn  an  irrrjrnlar  lint-  of  iliinanatioii.  In  tin-  lU-eptr  |i 
tioiis  tlicM-  .-olunuis  of  carlilaK*'  «'ll^.  instead  of  giving  platr  to  t 
hony  lanulhi'.  pass  into  an  arou  of  osteoid  tissue,  p«K)riy  suiipiit"*!  w 
hone  salts.  I  lere  and  tlure  masses  of  the  eartilnge  may  herome  isola 
and  snrronndeil  hy  the  osteoid  tissue.  This  zone  of  osteoid  tis 
passe.>i  more  de»'ply  into  the  niedullated  lione  than  normal,  hut  graihii 
givt's  j)laee  to  l)one  proper,  although  there  may  Ik-  an  intermeili 
zone  ill  wliieh  the  central  areas  of  the  lamella-  contain  bone  salts  \vl 
the  i)eripheral  i)ortions  are  devoid  of  thes*-  salts. 

H»-t\veen  the  osteoid  lamellie  are  relati\ely  wide  chamiels  fillwl  w 
a  marrow,  containing  sparse  marrow  cells  projKT,  hut  showing  spin 
cells  and  fine  fibrils,  a  more  fibrous  marrow  than  normal.  This  n 
unihrgo  a  direct  metaplasia  into  osteoid  tissue.  AVith  i)rogressing 
this  osteoid  tissue  exhibits  a  more  and  more  com|)lete  dei)ositioii 
calcareous  salts  until  the  whole  of  the  lamella'  may  take  on  the  nori 
appearance,  and  the  bones  become  of  almost  ivory  hardness,  with  sii 
Haversian  canals,  rcriosteal  bone  is  not  laid  down  regularly,  but  wl 
its  development  is  arrested  in  ccrtr.in  areas  it  is  aj)!  to  be  excessivt 
others,  osteophytes  being  i)rodnced. 

Infantile  Scurvy  ( linrlnw'n  Dismsr).  Tliis  disease  is  on«'  of  rec 
observation,  it  having  been  unrecognized  prior  to  the  employni 
of  pasteurized  milk  and  various  sterilized  milk  prei)arations.  I( 
unknown  in  children  fed  upon  the  mother's  milk,  and  presents  it 
first  as  an  exquisite  tenderness  of  the  limbs  so  that  the  child  screi 
upon  being  movtfl.  I'pon  post  mortem  examination  this  tenden 
is  found  to  have  its  cause  in  an  acute  congestion  of  the  periosti 
with  the  development  of  subperiosteal  hemorrhages;  hemorrhage  in 
medulla  may  also  be  present.  The  nutrition  of  the  bones  is  gra\ 
aH'ccted:  they  are  of  lighter  build  than  normal  with  a  tendency 
fracture  and  curvature.  Hemorrhage  may  occur  in  other  organs  ; 
recall  those  associated  with  scurvy.  As  in  that  disease,  so  lure, 
exhibition  of  fruit  juices  is  found  to  arrest  the  progress  of  the  comliti 
there  is,  on  the  other  hand,  a  certain  likeness  to  rickets,  e.  g.,  soften 
and  curvature  of  the  bones. 

Progressive  Changes. — The  important  subject  of  the  repair  of  b 
with  callus  formation  has  been  touched  upon  by  us  on  p.  192;  as  i 
we  have  dwelt  to  a  considerable  ext  upon  the  diflferent  order; 
primary  tumors  of  bones  in  the  sectioiis  uixm  myelomas  (p.  236)  i 
osteomas  (p.  2:].")).  Here  we  need  only  rei)eat  that  it  is  in  very  ni 
eases  difficult  to  draw  the  line  between  local  hyperplasias  and  tlic  t 
tumors  of  bone,  and  that  true  i)rimary  benign  tumors  are  really  in 
quent,  most  of  tin-  osteomas  being  hyj)erostoses. 

Tumors.—  We  thus  recognize  circumscribed  hy|)erostoses-  exosxo 
localized  bony  formations  of  periosteal  origin  projecting  from  thcsurl 


iki 


Tift:  H0.\  KS~TUMORS 


680 


dl'  till-  Im)Ius  and  enostoses,  originating  from  th«>  siHingiosu.  Of  similar 
Milt  lire-  arc  tliv  ossifyinf  ecchondroMS,  niMlnlar  ovt-r^'rowtlis  projecting 
triiiii  tlic  iMine  in  tin-  rc^cions  where  there  liad  U-en  previous  chondri- 
lonii  developments,  notahly  in  the  r»-gion  of  the  epiphyses.  These 
liii\(-  a  superficial  layer  of  cartiluRc  and  often  a  small  hursu  over  their 
Iri'i-  aspect  (ezostMis  bursata),  and  may  he  nniltiple. 

Oilier  Itenign  connective  tissue  overgrowths  of  tht-  hone  are  rare, 
ii  \\(-  leave  out  those  originating  from  the  periosteum.  If  we  include 
tlusc,  fihromas  of  the  hone  are  occasionally  met  ifibrons  •polis),  as  also 
iiii-iipliaryngeal  polyps  of  fihromatons  nature,  originating  from  the 
|Hri  i-tciiin  of  the  hase  of  the  skull  or  the  walls  of  the  nasopharynx. 
I'lin-  mjrxomu  were  very  rare,  mjrxo-chondromas  :itid  mjrxo-sarcomaa 
Minn-  foinmon. 

'rumors  originating  from  the  hone  marrow  tnay  Iw  of  the  relatively 
111  iii^jii  tyjH',  so-called  giuit-celled  sarcoma,  which  we  regard  strictly  as 
III!  o^ti-iK-liistic  fiant-celled  myeloma. 

Myeloma  multiplex  may  he  regarded  as  a  diffuse  Mastoinatoid  over- 
^niwtii  of  the  marrow,  and  may  hecomp.i  i  of  more  than  one  tyin  ^f 
iiiiirrow  (I'll  (see  p.  2;{()).  Sin  !'•  angiomas  are  rare,  hut  there  are  a  ^  .- 
iHMsof  a  remarkal>!chemangio-endothelioma(m  record,  involving  parti  i 
i  .rl\  till-  hones  of  the  calvarmm  and  showing  channels  filled  with  IiUmmI 
ainl  lined  hy  an  almost  cuhical  endothelium.  Intermediate  tumors  of 
till-  nature  of  osteosarcoma,  osteoid  sarcoma,  chondro-osteo-sarcoma,  and 
chondro-sarcoma  arc  to  he  found.  The  most  frecjuent  form  of  hone  tumor 
i-  iniiligiiant  and  sarcomatous.  We  distinguish  sarcomas  of  periosteal 
;iMil  of  endosteal  origin.  The  former  prtwluce  large,  o\al  masses  of  new 
lirowtli  surrounding  or  s[)rcading  over  the  surface  of  the  affected  bone; 
tluy  may  he  round  or  spindle-celled.  What  is  more,  a  tumor  arising 
litriii>teally  may  invade  the  shaft  of  the  hone  causing  its  absorption. 
Tlii'^i-  lire  more  fre(iuent  than  tlie  central  sarcomas,  which,  again, 
cxduiliiii;  the  giant-celled  myelomas,  may  be  round,  spindle,  or  mixed 
ii'll-  'I'liese  central  sarcomas  are  liable  by  progressive  absorption  of 
till  -iirroimding  bone  to  give  origin  to  spontaneous  fracture. 

1  III  -<•  malignant  sarcomatous  tumors  of  bone  show  certain  features 
ill  ri'iiimuii,  viz.,  they  are  apt  to  be  extremely  vascular  and  may  present 
txit  ii-i\(-  hemorrhages,  or  later  these  hemorrhages  may  give  place  to 
'.  t  -.  or,  again,  may  be  accompanied  by  extensive  necrosis;  the  growths 
may  vprtad  into  the  surrounding  soft  parts,  and  the  nearby  lymphatic 
iiikIi   .  iiiid  frequently  att'ord  metastases  in  the  lungs. 

A-  to  secondary  growths,  many  cases  are  on  record  in  which  thyroid 
ti-Mii  has  been  found  forming  circumscribed  tumors  within  the  bones. 
Whiii  jirimary  epithelial  growths  do  not  exist,  it  is  striking  how  certain 
'iir  !  iiiiis  of  particular  organs  show  a  predilection  for  extension  into 
!i<  s.  This  is  notably  the  case  with  prostatic,  and,  to  a  less  extent, 
mammary  cancers.  So,  also,  is  it  with  the  mesothelial  hyper- 
•iiia  wliicli  may  airt)rd  metastases  in  bones  eiilier  b^v  extension 
I  distance. 


th. 

wit 
til  i 
(ir 


69() 


THE  MOroU  AM)  TKGUMEXTARY  SYSTEMS 


«i   . 


A  useful  distinction  iM-tween  jH-riostfal  aud  endosteal  saroomuj 
that  the  former,  while  they  may  have  a  framework  of  radiating  Ix 
spicules,  possess  no  covering  layer  of  bone;  the  endosteal  sarcoma, 
the  contrary,  as  it  expands  and  causes  the  absorption  of  the  bony  tis; 
in  its  neighborhood  is  apt  for  long  to  remain  covered  by  a  layer  of  p( 
osteum  which  layer,  no  matter  how  great  the  exi)ansion  of  the  tuin 
contiiuies  to  give  origin  to  bone  and  thus  this  form  of  sarcoma  is  ; 
to  be  covered  by  an  imi)erfect  tliin  bony  layer,  so  thin  that  on  pressi 
it  affords  an  "egg-shell  crackle." 

Cysts. — Cysts  may  originate  in  bone  either  in  connection  with  ii 
growths  or  with  osteitis  deformans  as  tlie  result  of  localized  necroi 
with  or  without  hemorrhage,  and  subsequent  autolytic  absorpt; 
of  the  necrosed  matter.  Parasitic  cysts  are  of  great  variety, 
connection  with  the  jaw  c\sts  of  another  order  may  develop,  v 
the  dentigerous  cysts,  formed  around  accessory  and  imperfect  toi 
germs;  they  may  be  either  nni-  or  muitilocular,  the  latter  being  of  1 
nature  of  cvstadcnoma. 


THE  JOINTS 


\ 


Each  joint  consists  «)f  a  cavity  containing  a  s|)ecial  fluid— the  syi 
vial  fluid — interi)osed  between  two  or  more  bones  which  in  this  w 
become  capable  of  ino\  ing  oni'  against  the  other.  This  cavity  exti  n 
somewhat  beyond  the  apposed  surfaces  of  the  fntnes,  and  is  linm 
an  endothelium  composed  of  one  layer  of  cells,  which  '  ■  yond  t 
apposed  surfaces  rests  upon  abundantly  vascular  tissue.  Outside  th 
again,  is  an  outer  fibrous  layer,  wiiicl.  liere  and  there  becomes  nu 
condensed  and  reinforced  to  form  the  ligaments.  Upon  the  apjjos 
surfaces  the  synovial  endotlielium  is  more  flattened  and  rests  alni( 
immediately  upon  the  dense  thin  laver  of  cartilage  covering  so  niu 
of  the  heads  of  the  bones  as  are  liable  to  move  one  ujjon  the  otlu 
.\t  the  junction  of  the  .synovial  membrane  covi  ring  the  joint  and  t 
outer,  saccular  prolongation,  the  membrane  is  apt  to  be  developed  in 
a  series  of  small  papillate  processes,  the  synovial  fringes.  The  syiiov 
fluid  is  not  a  simi)le  serous  Huid,  but  contains  mucin  and  albumin 
as  to  have  a  somewhat  slimv  character  aoDropriate  for  a  lubricjitii 
Huid 

Abnormalities.  Iiu  I  ue  la.xity  of  the  joints,  brought  about  by  \i»>- 
iicss  of  the  ligaments,  and  favoring  easy  disKx'ation,  is  occasionally  im 
The  condition  is  generally  nuiltiple,  affecting  several  joints.  Mi> 
serious  conditions  arc  those  due  to  iiuperfect  development  of  the  Ikui 
entering  into  the  formation  of  the  joint.  This  is  seen  more  especial 
in  connection  with  the  hii)-joint,  where  the  head  of  the  femur  is  iniiH 
fectly  developed  and  coincidently  the  acetabulum  does  not  beinri 
adequately  hollov.ed  out,  so  that  there  is  no  proper  seizure  of  the  In ; 
within  the  acetabular  ca\  il\ ,  and  in  the  upriglit  posture,  llic  i.i . 
of  the  femur  is  forced  upward  over  th'-  wing  of  the  ilium  (congenit 


m 


THE  JOINTS 


691 


dislocation  of  tiie  hip).    A  similar  loost'iuss  and  imperfect  formation 
iiiiiy  atVect  the  knee  and  other  joints,  in(luein<;  subluxation. 

Circulatory  Disturbances.— These  are  ineonsiderahle;  thns  anasarca 
i>  not  aeeonipanied  hy  any  excessive  accumuhition  of  fluid  in  the 
>,\  iio\  ial  cavities.  Through  trauma  there  may  be  hemorrhage  into  the 
joint  and  the  resultant  coagulation  may  lead  to  the  development  of 
one  form  of  false  body  therein,  often  subsequently  absorbed. 

Inflammation.  — A  notable  feature  of  inflammation  of  the  joint 
la  thritis)  is  the  sympathetic  inflammation,  exudation  and  swelling  of 
tli  •  soft  tissues  around  it.  Xor  is  the  extent  of  this  swelling  by  any 
iiiians  a  sure  indication  of  the  severity  of  an  arthritis;  an  acute  "strain" 
of  till!  ligaments  may  be  rai)idly  followed  by  intense  surrounding  swell- 
in^',  iiltlujugh  the  actual  injury  to  the  joint  is  of  simple  nature,  slight 
iiiiil  localized. 

I'ollowing  contusions  there  is  in  addition  to  this  surrounding  swelling 
a  rapid  increase  in  the  serous  contents  of  the  joint  cavity  so  that  in 
tile  knee,  for  example,  the  i)atella  is  "floated"  or  pressed  away  from 
the  underlying  bony  surfaces.     This  serous  arthritis  is  secondary  to 
liMHiir.iia  and  is  the  simjjlest  form  of  exudate,  with  few  leukocytes. 
It  tends  to  undergo  absorjrtion   but   occasionally  the  inflammation 
!)•■(  nines  chronic  with  thickening  of  the  synovial  membrane,  vasculari- 
zation and  proliferation  of  its  surface  layer.    The  forms  of  trauma 
Mtting  n|)  serous  arthritis  may  be  various,  either  a  contusion,  a  "  strain," 
a  loose  cartilage  or  the  sudden  entrance  of  the  same  or  other  lo(»se  body 
HI  the  joint  between  the  joint  surfaces.     With  more  acute  irritation 
till  re  develops  the  condition  of  serofibrinous  arthritis;  the  fluid  in  these 
liiM >  is  no  longer  clear  but  turbid,  and  if  the  joint  be  oi)ened  there  is 
iiit.iiM'  liyperemia  of  the  synovial  membrane  with   slight  fibrinous 
||<|>oMts  in  the  recesses  of  the  synovial  sac.     The  turbidity  is  due  to 
an  uiireased  migration  of  leukocytes  into  the  fluid.     More  severe  and 
il'  -triK  live  inflammation,  due  to  the  jjresence  of  pyogenic  organisms, 
rcMiiis  ;n  suppurative  arthritis.  With  this  the  synovial  membrane  becomes 
•Toilcij  and  more  particularly  there  is  apt  to  be  a  degeneration  and 
iToHiii  ()f  the  joint  cartilages,  following  upon  which  the  jmurss  may 
<'\ii  11(1  into  the  bone  setting  up  an  osteo-arthritis.     Where  these  erosions 
taki   iil.icc  there  is  a  process  of  healing  if  the  joint  be  kept  immobile: 
■kIIh   ions  may  occur  between  the  apposed  joint  surfaces  and  with  organ- 
izatinii  and  formation  of  dense  connective  tissue  across  the  joint  cavity 
til'     iiovenicnt  of  the  joint  is  almost  entiicly  arrested.     Where  the 
'I'  HiKtion  has  been  very  extensive  there  may  indeed  be  developed 
111  iMTsal  adhesion  between  the  two  surfaces  and  in  the  process  of 
'"ony  ankylosis  be  set  up,  true  bone  rei)lacing  the  fibrous  tissue, 
y  be  noted  that  where  serous  and  serofibrinous  inflannnations 
111,'  contiiuied,  with  voluntary  immobilization  of  the  joint  by  the 
r.  altiiough  the  joint  'surfaces  arc  not  invoh-ed,  nevertheless  the 
iiing,  fibrosis,  and  shortening  of  the  synovial  membrane  and  the 
iits  may  also  lead  to  rigi<lity  and  to  a  iondilion  of  false  ankylosis. 


a 

tiiii 
it  1 
arc 

Mil' 

tlih 
iiu.' 


I 


ill 


,: 


I 


V      I 


092 


THE  MOTOR  AND  TEGUMENTARY  SYSTEMS 


Possibly  our  clinical  distinctions  of  the  various  forms  of  acute  artlu 
are  at  the  present  day  inadequate.  Gradually  we  arc  coming  to  rec 
nize  by  bacteriological  studies  that  several  different  microbes  are  capj 
of  inducing  what  clinically  we  term  acute  rheumatisin  or  rheum 
fever.  This  term  is  employed  to  designate  a  condition  of  obvi 
infection  with  high  fever,  redness,  pain  and  swelling  of  one  or  mi 
joints,  presenting  itself  with  considerable  suddenness.  Wherever  i 
occurs,  we  believe  that  we  deal  with  a  bacteriemia.  Sometimes 
condition  shows  itself  as  a  complication  of  known  infections,  c. 
gonorrhoea,  scarlet  fever,  etc.,  at  other  times  following  acute  ton 
litis,  at  others  with  no  recognizable  source,  and  when  bacteriolog: 
exi.  ninations  arc  made  in  one  group  of  cases  we  encounter  the  go 
coccus,  in  others  streptococci,  in  others  the  diplo-streptococcus 
Pcnnton  and  Paine,  and  in  yet  others,  we  obtain  negative  resu 
The  transitory  nature  of  the  polyarthritis  in  scarlet  fever,  and  ag 
after  the  administration  of  sera,  suggests  that  not  only  bacteria  I 
toxins  are  capable  of  setting  up  joint  irritation.  In  these  last  cai 
we  probably  deal  with  a  serous  arthritis,  but  as  regards  the  conditii 
set  up  by  the  actual  bacteria,  it  is  evident  that  according  to  their  vi 
lence  we  may  have  a  serous,  a  serofibrinous,  or  a  suppurative  arthri 

This  purulent  arthritis  is  characterized  by  two  series  of  events; 
the  one  hand,  it  is  apt  to  originate  by  i>xtension  o{  the  suppurat 
process  either  from  the  surrounding  soft  tissues  or  from  the  bone, 
again  from  traumatic  entrance  of  infection,  and,  on  the  other  ha 
is  apt  to  extend  beyond  the  limits  of  the  joint  cither,  as  above  no 
into  the  bone  itself  or  into  the  surrounding  soft  tissues,  or  both. 

There  is  a  condition  which  it  is  usual  to  include  among  the  cliro 
joint  diseases,  but  which  wc  are  convinced  should  be  more  prope 
regarded  as  an  acute  disease,  as  a  recurrt^nt  acute  or  subacute  artlirii 
we  refer  to  arthritis  deformans.  Here  over  long  years  the  patient 
subjected  to  a  succession  of  slightly  febrile  attacks  with  acconipanvi 
exacerbations  of  |)ain  and  swelling  of  the  joints  and  the  periartidi 
tissues.  With  this  the  joints  show  progressively  increasing  deform 
and  progressive  inflammatory  thickening  of  the  surrounding  soft  par 
The  histories  given  indicate  that  there  has  been  primarily  a  pure  arthri 
hut  with  successive  inflammations  the  process  extends  into  the  appn'^ 
ends  of  the  bones  leading  to  a  rarefaction  of  apposed  surfaces  \\i 
flattening,  compression  even  up  to  the  stage  of  cburnation,  ami  d 
tortion,  while  simultaneously  the  process  extending  to  the  perio-tn 
in  the  neigliborhoiul  induces  there  a  proliferative  overgrowth,  often  wi 
"guttering"  and  subsequent  locking  of  the  joint,  the  whole  a''comi):ini 
by  great  deformity.  We  have  seen  such  a  joint  after  many  mj 
showing  purulent  contents,  though  this  is  probably  an  unusual  cmi 
Worthy  of  note  is  the  involvement  of  the  spine  in  this  disease  (spend 
litis  deformans).  Here  the  inflammation  spreads  to  the  ptrioMii 
and  ligaments  of  the  vertebne,  and  with  the  new  bony  growth  :h 
results,  there  is  developetl  a  complete  sujK'rficial  ankylosis  Im    ii 


TUBERCULOSIS  OF  THE  JOINTS 


693 


in<livi(lual  vertebrae,  with  or  without  accompanying  distortion  and 
curvature. 

Chronic  Rheumatism. — Apart  from  the  specific  forms  presently  to  be 
considered,  there  is  a  certain  number  of  cases  which  appear  to  be  the 
result  of  a  latent  or  continued  process  such  as  is  seen  in  acute  rheu- 
matism; these  are  characterized  by  great  thickening  and  shortening  of 
tlic  synovial  membrane,  the  fibrosis  extending  to  and  involving  the 
surrounding  ligaments;  with  this  the  "artilage  of  the  joints  undergoes 
(If^rcneration  and  at  times  replacement  by  fibrous  tissue  and  either 
there  may  be  adhesions  developed  or  with  atrophy  of  the  heads  of  the 
hones  the  joints  may  undergo  subluxation.  Unlike  arthritis  deformans 
tlicrc  is  here  little  or  no  periosteal  activity  and  new  bone  formation. 
It  lias  been  called  arthritis  pauperom. 

Tuberculosis.— Two  joints  stand  out  as  peculiarly  liable  to  be  the 
scat  of  tuberculous  affection,  the  hip  ("hip-Joint  disease")  and  the  knee 
("white  swelling").  Less  frequently,  but  still  often,  the  ankle,  wrist, 
and  elbow  are  effected.  As  to  the  mode  of  origin  of  the  disease,  this 
nia,\  he  said,  that  the  joint  disease  rarely  accompanies  generalized 
tuberculosis;  more  frequently  it  is  present  for  months  or  years  before 
the  disease  shows  signs  of  generalization.  As  to  the  mode  of  develop- 
ment two  main  forms  are  recognized:  (1)  that  in  which  the  bone  in 
the  immediate  neighborhood  has  been  first  involved,  and  by  caseation 
ami  necrosis  the  joint  surface  has  become  invaded,  so  that  the  joint 
as  a  whole  becomes  infected;  this  appears  to  be  the  more  commor ;  and 
r2)  where  the  synovial  infection  is  primary,  tubercles  forming  in  the 
inner  layer.  In  either  of  these  cases  it  is  usual  to  speak  of  the  disease 
as  primary  in  the  one  part  or  the  other,  but  it  must  be  remembered  that 
arronliiig  to  general  belief  the  actually  primary  fucus  is  in  the  lungs 
or  <lsewlitre,  even  although  this  focus  may  in  the  meantiir°  undergo 
arrest  while  the  process  advances  in  the  neighborhood  of  the  joint. 
The  syn<>vial  form  occasionally  is  of  acute  development  inducing 
an  al)un(iant  serofi^  us  exudation;  more  frequently  this,  like  that 
<iri;;inating  from  .•  !i>  has  a  chronic  course,  viz.,  with  the  formation 
"t  tui)erclcs  on  ti  -  vial  membrane  and  surrounding  inflammation; 
thiii  membrane  e:.  ,■  proliferation  and  fungoid  overgrowth,  becomes 
iK'iil.ly  thickened,  and  not  only  is  the  outer  layer  involved  but  the 
surrnnnding  soft  tissues  become  infiltrated  with  the  tubercular  growth 
I  -woilen.  With  caseation  and  breaking  down  of  the  infected  tissue 
'  may  be  final  fistula  ft)rmation.  Coincidently  with  these  processes, 
I'oiu-  if  not  i)rimarily  the  seat  of  infection,  becomes  secondarily 
Kc(i  in  a  rarefying  tuberculous  osteitis  with  necrosis  (caries). 
.  as  in  arthritis  deformans,  there  may  be  a  coincident  suiKrficial 
iituin  of  bone  by  the  periosteum  in  the  neighborhood  of  the  inflamed 
in  the  form  of  osteophytes. 

philis.     In  the  congenital  disease  an  exudative  form   has   been 

led  with  disintegration  of  the  cartilages  and  fibrosis  and  thicken- 

tlu-  capsule.     In  acquired  syjjhilis,  there  may  be  an  acute  serous 


an 

th. 

tin 


(594 


THE  MOTOR  AM)  TEGUMESTARY  SYSTEMS 


or  serofibrinous  arthritis  in  the  eruptive  stage,  or  later  there  may 
small-celled  infiltration  or  gummatous  formation  in  the  synovial  mt 
brrnes,  either  primary  or  secondEry  to  a  syphilitic  osteitis  or  periostei 

Regressive  Changes. — Atrophy. — The  most  imiM)rtant  degeneratii 
occur  in  connection  with  the  joint  cartilages.  Here  we  may  encouii 
either  a  fatty  degeneration  or  a  necrescent  state  of  the  cartilage  c 
and  with  this  a  coincident  dissolution  of  the  matrix.  This  is  «)ften  v 
characteristic  in  old  age;  the  matrix  becomes  more  mucoid  and 
fibrillation  becomes  prominent.  The  general  result  is  that  urn 
pressure  the  cartilage  shows  a  tendency  to  ulceration  with  secondi 
sclerosis  and  eburnation  of  the  exposed  underlying  bone.  In  ot 
areas  the  degeneration  may  be  followed  by  some  ])roliferation  of 
remaining  cartilage  cells,  and  calcification  with  opacjue  whitening 
these  areas  may  eventuall\'  show  itself. 

The  remarkable  condition  of  ochronosis  is  characterized  by  a  d( 
brown  or  blackish  coloration  of  the  cartilage.  It  is  very  rare  si 
little  definite  is  known  about  its  causation.  It  must  be  rememl)e 
that  cartilage  has  an  affinity  for  iron  aiu'  also  for  blood  pigment  t 
that  thus  if  there  be  hemorrhages  in  the  leighborhood  of  the  joint, 
cartilage  may  b--,ome  the  seat  of  a  hen^atoidin  pigmentation. 

Gout. — AnothfT  infiltration  that  is  very  characteristic,  is  that  s( 
in  the  gouty  joint,  especially  the  metatarso-phalangeal  joint  of 
great  toe.  Here  the  cartilages  either  generally  or  in  patches  may  ti 
on  a  chalky  white  opacity,  which  is  found,  upon  microscopic  exami 
tion,  to  be  due  to  a  dense  infiltration  of  the  Mstrix  with  fine  acicii 
crystals  of  sodium  biurate  (see  p.  107).  The  same  deposit  may  be  si 
in  the  synovial  membrane  and  its  imderlying  soft  tissues  and  liganiei 
In  the  surrounding  tissues,  the:  e  deposits  may  occur  as  tophi  or  sn 
hualized  ncMlules.  In  general,  if  the  crystals  be  dissolved  out,  i1 
found  that  the  cartilage  is  necrosed,  whether  as  a  preceding  oi 
sequent  process  is  yet  debated. 

Neuropathic  Atrophy. — In  the  course  of  some  cases  of  locomotor  ata 
and  syring(miyelia  it  may  hapi)en  that  with  complete  absence  of  ]) 
an  individual  joint,  such  as  tiie  knee-joint,  may  :  idergo  a  relativ 
rai)id,  non-infianunatory  eft'usion  of  fluid  into  the  joint  cavity  w 
coineidt-nt  atrophy  of  synovial  membrane,  cartilages  and  bone,  whin 
in  a  very  short  period  there  is  develojjcd  a  greatly  disorganized  jo 
cavity  with  a  flail-like  motion  of  the  limb  in  all  directions.  Til!^ 
known  as  a  "Charcot's  joint."  We  arc  still  unable  to  ascribe  any  <ai 
to  this,  but  conclude  vaguely  that  here  we  deal  with  atrophic  disonl 
due  to  the  destruction  of  the  sensory  portion  of  the  reflex  arc.  T 
does  not  satisfactorily  explain  why  only  a  single  joint  is  involved, 
may  be  recalU-d  that  a  singular  rapid  atrophy  of  bone  is  seen  in  -n 
cases  of  anesthetic  leprosy. 

Foreign  Bodies.  -  Foreign  Ixxlies  in  joints  may  be  of  more  tluin  < 
order.  The  corpora  oryzoidea,  often  fi>\m<i  in  the  tuberculous  i"i 
are   little,   translucent    rice-grain-like   bo<lies,   sometimes    eon<t:ili 


THE  SKIX 


695 


t'drmed  of  hyaline  material  with  occasional  indications  of  cells.  These 
iirc  rcfjanled  either  as  masses  of  hyaline  fibrin  or  as  dissociated  oortions 
(if  necrosed  granulation  tissue.  As  already  noted,  fibrinous  masses 
from  old  blood  clots  may  form  soft  foreign  bodies;  pieces  of  the  synovial 
fringes  may  be  nipped  off  and  become  free  in  the  joint  cavity.  In 
addition  there  may  l)e  firmer  loose  bodies  formed  of  snared-off  pro- 
jections of  the  synovial  membrane  which  have  previously  undergone 
(iirtilaginous  or  bony  metap!      i. 

Progressive  Changes. — Metaplasia,  as  already  noted,  is  not  infre- 
(|iu'nt  in  connection  with  the  joint  cartilage.  This  may  become  con- 
verted from  the  hyaline  to  the  fibrous  form  and  again  may  become 
(■(inverted  into  simple  connective  tissue,  which,  in  its  turn,  may 
undergo  ossification.  So,  on  the  other  hand,  the  synovial  fringes  may 
either  become  so  fatty  as  to  be  lipomatoid  or,  on  the  other  hand, 
may  sliow  cartilaginous  change,  while  in  arthritis  deformans  bony 
jilates  may  form  in  the  synovial  membrane. 

Tumors. — The  synovial  irpiges  may  show  a  diffuse  fibromatous  or 
lipomatous  change.  The  so-called  lipoma  arborescens  originating  in  these 
fringes  has  been  recorded  in  several  cases  of  tuberculous  arthritis  and 
arthritis  deformans.     Sarcoma  of  the  synovial  membrane  is  very  rare. 


l! 


THE  SKIN 

Since  most  of  the  diseases  that  affect  the  skin  produce  effects  that 
are  suiierficial  and  visible,  it  is  obvious  that  the  pathological  effects 
and  tile  clinical  signs  of  these  diseases  will  be  largely  identical;  we  will 
tlicrefore  deal  with  all  these  in  the  most  brief  way.  The  circulatory 
aitivity  in  the  skin,  the  secretion  and  excretion  jx-rformed  by  it,  its 
fuiii  tioii  as  a  sense  organ-all  these,  as  well  as  its  exposed  sitilation— 
n  iid(  r  it  the  seat  of  changes  more  active  and  more  numerous  than 
ini^ht  l)e  at  first  thought. 

Abnormalities. — The  skin  may  be  locally  unpigmented  in  areas  that 
an  irregular  in  size  and  shape,  and  pure  white  (leukoderma).  A  general 
aiiM  nee  of  pigment  in  the  skin  and  other  pigment-containing  areas 
(nil  titutes  albinism.  Excess  of  pigment  is  found  in  pigmented  moles, 
whirh  are  usually  brown  or  brown-black.  An  interesting  congenital 
^tati'  is  ichthyosis  in  which  there  is  great  keratinization  following  upon 
liMutrophy  of  the  skin;  large  fissures  appear  in  the  surface,  and  the 
-kill  lieeomcs  like  that  of  a  fish  or  an  alligator.  There  may  be  much 
ati.  pliy  (if  tlie  active  layers  underlying  this  superficial  hypertrophy. 

1  lie  nails  may  be  absent  or  hypertrophied,  and  the  hair  absent, 
']<■■■' -r.  or  abundant.  Hypertrichosis,  hirsuties  or  hairiness  may  be 
i-'i !  ral.  the  entire  surface  except  the  palms  and  soir  being  affected, 
ii  I  ndition  which  is  resjMJnsible  for  the  "dog-faced-man"  of  museums. 
I.'    ili/ed  hypertrichosis  is  seen  on  moles  and  over  occult  spina  bifida. 

tirculatory  Disturbances.— Anemia  is  manifested  by  the  skin  in 
^'         of  general   IxMlily  anemia,  and  locally  and  temporarily  from 


m 


m^mm^m^ 


^SP^^^RH-^Tf! 


690 


THE  MOTOR  AXD  TEGUMEXTARY  SYSTEMS 


a  ! 


^;^ 


cold,  pressure,  and  emotion  or  other  purely  nervous  influences, 
facial  pallor  in  a  fainting  attack  will  api)eal  to  all  as  a  familiar  exatnj 
Acute  hyperemia  consists  of  a  temj>orary  dilatation  of  the  superfii 
capillaries,  the  skin  becoming  pink  or  red;  this  may  he  the  response 
different  kinds  of  stimuli,  such  as  heat,  cold,  emotion,  e.  g.,  hlushi 
friction,  a  chemical  irritant  or  may  be  the  early  stage  of  inflammati 
Passive  hyperemia  is  seen  in  conditions  of  general  Aenous  coi"'esti 
as  in  suffocative  attacks  or  severe  fits  of  coughing,  in  overfilling  of 
heart,  and  impeded  respiration  from  any  cause.  The  skin  then  assui 
a  dusky  tint,  and  the  mucous  membranes  may  be  bluish  or  lead  colo 

^anosis,  lividity).  In  cases  of  severe  long-continued  passive  hyj 
eniia,  oedema  or  anasarca  may  supervene,  with  the  result  that  the  tis 
l)ecomes  smooth,  tense,  and  shiny,  the  skin  and  the  underlying  lo 
tissue  being  "waterlogge<l." 

Hemonhage  into  the  skin  may  occur  from  trauma,  from  extrc 
infections  in  which  i)etechiie  are  seen,  or  from  the  "'hemorrhag 
diseases,  especially  scurvy.  Inthe  last-namwl  the  extent  of  the  hem 
rhagic  patch  may  be  considerable,  and  in  marked  contrast  to  the  exti 
may  be  the  superficiality  on  section.  The  \arious  tints  assumed 
the  skin  after  hemorrhage,  due  to  chemical  changes  in  the  pigment, 
familiar.  The  occurrence  of  hemorrhage  in  the  skin  is  usually  de> 
nated  by  the  term  purpura  (see  p.  35.')),  and  is  due  to  a  more  or  less  ra] 
degeneration  of  capillary  walls.  Finally  in  circulatory  disturban 
of  the  skin,  it  must  be  remembered  that  many  states  apj)earing  throi 
the  skin  do  not  actually  concern  the  skin  at  all,  and  are  connected  w 
underlying  tissues. 

Inflammation. — There  are  numerous  causes,  direct  and  indirect, 
which  the  skin  can  become  inflamed;  of  the  former,  woimds  of  all  soi 
friction,  chemical  irritants,  heat  and  cold,  bacterial  and  other  parasit 
are  the  most  important;  the  latter  comprise  noxious  agents  carried 
the  skin  by  the  blood,  as  well  as  those  disturbances  of  nutrition  a 
of  nerve  connection  which,  while  perhaps  not  effective  of  theniselv 
are  yet  strongly  predisposing  forces. 

While  the  main  feature  of  inflammation  of  the  skin  is  the  exudatic 
this  appears  in  a  great  variety  of  forms,  the  macule,  the  papule,  t 
vesicle,  the  pustule,  the  bulla,  the  node,  the  wheal,  all  of  which  t 
aptly  calle<l  primary  efflorescences  to  distinguish  them  from  cms 
scabs,  erosions,  ulcers,  furrows,  and  scales  which  are  the  secondu 
results  of  such  efflorescence.  To  apply  the  term  dermatitis  to  all  sii 
appearances  would  be  misleading  because  that  term  has  become  tint 
nally  restricted  to  particular  forms  of  inflammation  of  the  skin.  A 
attempt  at  classification  made  here  will  be  elementary,  nuTtly 
subdivide  a  too  bulky  list  of  diseased  conditions. 

I.  Inflammations  of  the  skin  due  to  systemic  disturbance. 

Measles.  -In  measles  the  skin  shows  round,  discrete,  flat  or  sliulit 
raised  red  or  bluish-red  spots,  2  to  10  mm.  in  diameter,  fading  to  yciic 
on  pressure,  which  under  exceptional  circumstances  may  be  heniorrluij 


m 


WP 


i 


ERYTHEMA 


697 


or  confluent.  The  exciting  organism  is  not  known,  and  tlie  skin  rash 
IS  distinctive  only  in  connection  with  the  systemic  signs  and  symptoms. 

Scarlet  Fever. — In  scarlet  fever  (scarlatina)  there  is  an  eruption  of 
jiii-head-sized  or  smaller  red  areas  (puncta*),  with  which  is  usually 
conibined  a  diffuse  reddening  of  the  otherwise  unaltered  skin,  both 
disapjiearing  on  pressure;  the  scarlet  tint  of  the  skin  is  characteristic. 

Erythema. — A  great  man>  forms  of  hyperemia  of  the  skin  are  grouped 
under  the  term  erythema — often  called  erythema  multiforme  because 
iil"  the  impossibility  of  distinguishing  these  from  one  another  in  their 
mitrphology  or  etio'ogy.  There  is  nothing  distinctive  about  the  red 
ureas  of  the  skin,  which  fade  under  pressure;  they  may  become  changed 
liy  hemorrhage,  or  by  the  formation  of  papules,  vesicles,  or  other  modi- 
fications. We  have  to  recognize  a  large  number  of  agents  which  can 
cause  erythema,  such  as  the  local  exhibition  of  heat,  cold,  chemicals  or 
iiuciiimical  irritants;  the  invasion  of  the  IxMly  by  some  toxin,  as  after 
the  ingestion  of  certain  drugs,  quinine,  turpentine,  salicylates,  mercury, 
(ir  of  certain  focxls  (this  often  an  idiosyncrasy),  shell  fish,  fish,  straw- 
luTfies,  etc.;  as  a  result  of  certain  infections,  as  seen  in  the  "roseola" 
of  typhoid  fever,  the  bacterial  agent  being  present  in  the  lesion;  as  an 
accompaniment  of  sapremia  in  many  different  infections,  and  after 
surgical  operations.  Finally,  many  cases  of  erythema  occur  in  which  \w 
cause  can  be  assigned,  and,  accompanied  as  these  often  are  by  gastro- 
iiilcstinal  disturbance,  we  suppose  that  toxins  elaborated  in  the  aliment- 
ar.\-  canal  oi  elsewhere  possess  the  ;  jwer  of  causing  this  manifestation. 

I'rythema  of  a  diffuse  type  or  localized  and  notlular  (noflosum) 
may,  of  course,  occur  in  specific  infections,  as  in  syphilis,  rheumatism, 
and  other  states.  In  designating  such,  we  are  accustomed  to  lay  more 
stress  upon  the  disease  that  we  know  to  be  the  cause  than  upon  the 

I -distinctive  erjthema — thus  in  sfwaking  of  erythema  syphiliticum 

uc  iiientally  underline  the  latter  rather  than  the  former  word. 

Urticaria.^ — I  lere  we  deal  with  not  only  a  hyperemia  but  also  with  an 

0  ilcni^'  of  the  tissues,  showing  itself  as  slightly  raised,  pink  or  yellowish- 
rcil  areas  (wheals)  of  any  size  and  shape,  with  a  slight  surrounding 
/'inc  of  hyperemia,  which  appear  quickly  and  may  as  quickly  disappear. 

1  I  miliar  to  most  people  as  the  homely  "hives,"  they  may  be  caused 
li>  nettles  or  a  like  external  irritant,  by  the  injection  of  the  various 
"I  la,  and  by  any  of  the  drugs  or  foods  or  toxins  mentioned  above;  they 
li.ivc  some  obscure  relation  to  the  nervous  system,  for  they  arise  in 
si.iii(>  persons  as  a  result  of  a  finger-nail  drawn  across  the  skin,  and 
Hi  iitlicrs  without  apparent  irritation  as  the  condition  of  angioneurotic 
|"l<  Ilia.  As  a  result  of  toxins  from  certain  foo<ls,  urticaria  is  a  more 
<   iiiinoii  phenomenon  than  is  erythema. 

I  i    Inflammation  of  the  Skin  from  Heat  and  Cold. 

Bumingf.-Tlie  dermatitis  set  up  by  heat  varies  according  to  the 
■  <!■  of  the  heat  and  the  length  of  time  in  which  it  acts:  burns  are 
'  illy  classifiefl  by  us  in  every-<lay  hospital  life  in  a  similar  way.  In 
'      !i<;Iitest  grade  of  burn,  such  as  sometimes  follows  bright  sunlight, 


\ 


^1 

i 

'■  i 


?• 


i    !' 


n 


ill 


COS 


THE  MnroH  A\D  TEdlMESTAHV  SYSTEMS 


there  is  active,  followed  by  passive  liypereinia,  au<l  u  iiuMlerate  anion 
of  swelling;,  followed  later  hy  a  brownish  eolor  of  the  skin.  More  sevf 
(ie^crees  are  attentleil  by  liftinji  of  the  (lama>;e(l  ( pitheliuni  by  t 
exudate  -the  bulla  or  blister.  The  eoverinj;  of  the  Imlla  may  degent 
ate,  or  the  eontei\ts  beeouie  infected  the  coriuin  is  almost  eertai 
sutler  in  such  a  case,  but  unless  severely  infeete<l,  scarrins;  is  not  likt 
to  ensue  More  severe  degrees  of  burning  are  followed  by  (lestructi( 
«tf  an.  11  of  the  parts  concerned,  leading  to  gangrene  or  to  dry  clii 
ring  of  the  tissues.  TIere  may  be  mentioned  the  j)arallel  cases  of  burni 
by  a--rays  an<l  t)ther  forms  of  radiant  heat;  the  burn  is  not  at  once  ei 
dent;  but  degeneration  and  cell  death  may  follow,  with  the  productii 
of  ulcers  which  are  hard  to  heal,  and  whose  healing  processes  seem 
readily  pass  on  to  new  growth. 

Freering.—  The  injury  in  slight  cases  of  frostbite  is  perhaps  as  mu 
tine  to  the  overactiou  of  rei)air  as  to  the  severity  of  the  original  lesi<i 
in  a  slight  frostbite,  as  soon  as  reaction  has  occurretl,  the  picture 
the  same  as  in  a  slight  burn;  in  severer  cases  blebs  occur,  and  in  t 
severest,  gangrene,  there  being  various  degrees  of  degeneration  evidei 
or  even  necrosis,  as  a  result  of  the  freezing  process. 

III.  Miliaria,  Herpes,  Eczema,  etc. 

Miliaria. —Miliaria  is  an  eruption  of  tiny  droplet-like  areas  of  e] 
thelium  lifted  by  secretion,  which  seems  to  occur  in  connection  espe 
ally  with  the  mouths  of  sweat  glands.  Its  causes  are  obscure,  h 
probably  inflammatory. 

Herpes.  This  is  an  inflammatory  disease  of  the  skin  occurring 
connection  with  the  peripheral  nerve  trunks  (see  p.  122),  appear! 
as  small  papules,  which  quickly  become  vesicles,  containing  clear 
turbid  serum;  with  the  drying-up  ])rocess,  crusts  forn^  uider  which  t 
epithelium  is  renewed.  According  to  <listributioii  there  are  mai 
varieties;  herpes  soster  (intercostal  nerves),  herpes  ittcialis,  and  herj 
preputialis,  are  conmion  forms. 

Pemphigus. — This  name  groups  together  many  diseases  of  vario 
origins,  which  are  alike  in  this,  that  there  are  produced  on  the  si 
vesicles  at  first  compartmented,  but  later  single-<hambered,  attain! 
large  size,  sometimes  that  of  a  goose-egg.  The  contents,  at  first  cici 
may  become  either  turl)id  from  fibrin,  epithelial  debris  and  leukocyt 
or  purulent  or  hemorrhagic.  The  surrounding  inflammation  often 
slight,  out  of  proportion  to  the  size  and  ajipearance  of  the  bulla.  Son 
times  ])emphigus  seems  to  be  of  an  acute  infective  nature  and  lei'.tls 
a  fatal  result;  it  is  seen  in  the  newl)orn  as  a  result  of  syphilis  and 
times  seems  to  be  dependent  largely  upon  the  nervous  system  tor 
origin. 

Eczema. — This  term  is  employed  to  indicate  an  ill-defined  infinniir 
tory  disturbance  showing  a  basis  of  diffuse  reddening  and  swelling,  up 
which  there  are  foci  of  more  i)r(w!uctivc  or  more  destructive  disti!r'i:it'< 
If  these  foci  take  the  form  of  papules,  we  speak  of  eczema  papulosa) 
a  verv  common  form  is  that  in  which  small  lenticular  vesicles  drvil 


RCZKM  A— IMPETIGO 


099 


•  ecsema  vesiculosum).  Tliesi'  are  pfirticiilarly  apt  to  rupture  under 
irritation  and  lead  to  (mziiiR  (ecsema  madiduu);  where  more  chronic, 
the  weepr^  surface  is  apt  to  Kive  rise  to  the  formation  of  scattere<l 
<rusts.  or  the  vesicles  may  become  pustules  (eciema  pustnlosum). 
As  a  result  of  the  chronic  (onditioii,  pigmentation  and  thickening 
of  the  skui  are  a|)t  to  he  seen.  In  attempting  to  define  eczema 
It  may  l)e  said  that  a  discrete  eruption  does  not  constitute  an  eczema; 
tiiere  must  Ik-  an  underlying  inHamed  basis.  If  there  be  simple  inflam- 
matioii  without  foci  of  further  disturbance  we  speak  of  ervthema;  if 
these  fo<i  of  further  change  occur,  of  eczema;  if  these  ft)fi  develop' to 
Mich  an  extent  as  to  overshadow  the  background  of  diffuse  infJammation, 
we  are  apt  to  speak  of  the  focal  disturbance  and  neglect  the  diffuse 
.l.rniatitis;  to  sj)eak,  for  example,  of  impetigo,  intertrigo,  etc.  From 
thr  pathologist's  jjoint  of  \iew  it  appears  as  if  eczema  were  a  term  used 
l>.\  ciuiicians  for  convenience  in  designating  many  forms  of  ilUlefined 
dermatitis. 

Impetigo.  -This  is  an  infective  disease  oftenest  of  the  face  and  hands 
itrc(iuently  by  transferenc*')  in  which  small  i)ustules  arise,  with  subse- 
(|iitiit  crusts.  The  connnon  form  is  designated  Impetigo  contagiosa, 
l.iit  from  the  nature  of  the  contents  one  would  judge  that  under  favor- 
iil.lc  circumstances  most  of  the  cases,  if  not  all,  would  prove  communic- 
.;il)le  \Ne  recall  that,  during  our  college  <lays,  an  epidemic  occurrtnl 
111  tli(>  fiHitball  team,  the  eruption  appearing  in  som    cases  behind  the 

•  iir,  where  the  skin  frequently  was  broken  by  the  auricle  being  pulled 
lorcibly  forward  in  the  pressure  of  the  scrimmage;  after  a  certain  match 
iii.iiiiiers  of  the  opposing  team  developed  a  similar  condition,  similarlv 
Inratcd,  the  result  of  head-and-head  contact. 

I\  .  Inflammation  of  the  Skin  Characterized  by  Pocks. 

Variola.  As  a  result  of  hematogenous  infection,  a  coagulation  necrosis 
'"  nirs  m  the  cells  of  the  rete  Malpighii,  with  a  cellular  exudation  from 
th.'  \isscls  of  the  papilla-;  by  the  action  of  pyococci  the  contents  of  the 
niniiy-chambered  pock  l)ecome  infected  and,  finally,  a  single-chambered 
pii  tiilc  results,  which  forms  a  crust  and  ultimatelv  mav  leave  a  scar 
Ol  til,.  sanH>  general  order  are  the  pocks  of  varicella,  and"  of  vaccinia. 

\ .  Psoriasis,  Lichen,  etc.— Psoriasis  is  an  inflammation  of  the  skin  in 
«l.iih  an  infiltration  of  the  epidermis  and  corium  occurs;  there  are 
I'Mu.tjitc  heaps  of  broad  plates  of  dry  epidermis  on  a  background  of 
^iyirply  dehned  reddened  skin  that  bleeds  easily.  The  epidermal  cells 
'j'  'li«'  stratum  corneum  dry  and  are  separated  into  large  plates  or 
'1;'''^  between  which  air  finds  its  way,  giving  the  characteristic 
^il  '  r\  apiM'arance  to  the  scales. 

Lupus  erythematosus,  in  no  way  connected  with  true  lupus,  is  an 
'j^  'innation  that  shows  itself  as  small  round,  raised  spots  with  a 
'!■    "  ssK.ii  in  the  centre;  these  l)ecome  covered  by  dry,  yellow  scales. 

'  dien  IS  a  ciironic  form  of  inflammation  with  papules  which  remain 
III  jiii},'ed  save  for  an  increase  in  size;  they  may  form  scales,  but  not 
\'      Its  or  pustules,  although  in  lichen  scrofulosum  there  may  excep- 


t 


^1   J: 


1- 


s  S 


I*      ^ 


700 


THE  MOTOR  AND  TEGUMENTARY  SYSTEMS 


tioimlly  l)e  tiny  piistult's  on  the  summits  of  tlie  papiilos.  The  moi 
of  thf  hair  follicle  is  th«'  part  atfi'ct«>«l,  a  ]M>rifolliciilar  inflammat 
and  hyjK'rkt'ratosis  resulting. 

\'I.  Erysipelas  and  Other  Inflammations  of  Known  Bacterial  Oricin. 

Erysipelas. — Tl>'s  is  an  infection  of  the  skin,  sometimes  by  way  of 
unrecojtnized  iesicm,  sometimes  by  increase  of  virulence  of  the  ccktI 
hair  follicles,  which  may  be  accompanied  by  great  or  by  slif(ht  systei 
disturbance;  often  the  latter  is  out  of  proportion  to  the  amount  of  s 
involvement.  Formerly  considered  dangerou.sly  infectious,  the  dise 
is  now  place«l  on  a  par,  in  this  regard,  with  other  forms  of  sepsis,  v 
danger  exists  chiefly  in  the  presence  of  wounds  or  great  bodily  wcakni 
The  lym[)h  spaces  of  the  connective  tissue  lodge  the  bacteria,  usut 
streptococci,  and  there  is  marked  hyperemia,  cellular  and  serous  e 
date,  which  pr()gresses  with  the  existence  externally  of  a  welUiefii 
line  of  denuircation.  The  skin  is  swollen,  shiny,  and  red.  Vesi( 
and  pustules  may  form  and  even  severe  necroses  may  follow. 

Abscess  or  Phlegmon. — Abscess  or  phlegmon  does  not  differ  grea 
from  the  above  in  its  hkhIc  »)f  origin;  fluid  exudation  and  the  distens 
of  the  tissues  are  more  evident.  The  result  of  infection  of  the  s 
may  be  a<litfuse  cellulitis  on  the  one  hand,  or  a  localization — absces 
on  the  other.  Hy  reason  of  concentration  and  bacterial  activity, 
abscess  may  attack  the  deeper  structures,  and  attain  consideni 
depth  before  the  pressure  l>ecomes  sufficient  to  break  through  the  s 
or  before  surgical  intervention  is  securc«l. 

Acne.— This  is  a  small  inflammatory  mass  originally  formed  in 
vicinity  of  a  hair  follicle  or  a  sebaceous  gland,  breaking  down  to  fi 
a  small  quantity  of  pus.  Acne  rosacea  has  a  different  origin;  hen 
found,  in  the  simplest  forms,  a  prominence  of  capillaries  over  the  surf 
of  the  cheek  or  nose,  while  in  severe  forms  there  is  a  marked  incre 
in  the  connective  tissue  and  the  glands,  which  latter  become  closed,  f 
a  great  deformity — a  kind  of  elephantiasis  of  the  nose — results. 

Furuncle,  Carbuncle,  etc. — The  furuncle  is,  pathologically  speak! 
an  acne  pustule  upon  a  larger  scale;  and  a  carbuncle  upon  a  yet  greu 
scale.  In  the  last,  by  reason  of  the  virulence  of  the  organism,  usui 
in  all  these  cases  the  staphylococcus,  there  is  apt  to  be  a  widespn 
necrosis  of  tissue  and  a  marked  systemic  disturbance.  When 
infection  is  not  staphylococcic  or  streptococcic  but  due  to  the  bacil 
of  anthrax,  the  lesion  is  designated  malignant  pustule.  In  necrosis  ii 
gangrene  the  skin  is  but  one  of  the  tissues  involved;  these  have  1m 
(h-alt  with  elsewhere  (p.  328). 

XTlcers. — Ulcers  of  the  skin  arise  in  many  different  ways,  and  n 
follow  many  causes;  the  essential  condition  is  a  loss  of  tissue  broiij 
about  in  other  than  a  sudden  way.  Normally  the  process  of  nj) 
comes  at  once  into  action,  and  according  to  the  completeness  of  t 
reaction  and  its  s})eed,  coupled  with  the  quality  and  amount  of  cx!'-'n 
the  ulcer  takes  certain  characters,  indicated  by  names  such  as  heali 
spreading,  indolent,  or  phagedenic.     The  tendency  of  new  growflis 


THE  SKl\'-^LUPUS—SYI'niUS 


701 


the  skin  to  uK-oration  is  very  great,  by  reason  of  their  F)o,)rlv-<ontrolle<l 
l)lo(K  supply  and  of  the  readiness  with  which  interferent-e  with  the 
circulation  of  the  skin  is  pnnluced. 

\'II.  Infective  Or»DalomM. 

Tuberculoeis.— Lupus  appears  as  a  ncHJular  eruption,  which  consists  of 
iiii  HKKlomeration  of  miliary  tubercles  surrounded  bv  an  inflanunatorv 
iiihltration,  seen  most  often  upon  the  face.  The  mMJules  may  Ik-  at 
tunes  hardly  visible,  but  may  be  felt,  and  if  a  mo<lerate  degree  of  absori)- 
tion  occurs,  the  area  may  be  ultimately  scarrwi.  but  in  some  part  of 
Its  coiirse  tilcerative  destruction  of  some  part  of  the  surface  is  almost 
file  rule.  .Scarnng  may  be  extensive,  and  there  is  a  ten.lency  for  the 
.  isease  to  recur  in  the  scar  tissue.  Histologically,  the  characters  of 
the  tuljereuloma  are  seen  amid  inflammatory  infiltration  bv  leukocytes 
and  plasma  cells.  Tul)ercle  bacilli  are  present  usualiv  in  small 
Munil)ers. 

The  so-calIe<l  scrofuloderma  or  sukutaneous  tuberculosis  consists 
ot  a  subcuticular  infection  often  in  the  neighborhood  of  tuberculous 
Kliinds  or  fistute.  The  infiltration  by  small  tuberculous  masses  with 
subsequent  mfiltration  of  the  skin  itself,  shows  itself  as  an  apparent 
a(  hesion  of  the  thmned  layers  of  the  skin  to  the  underlying  tissues  the 
whole  bemg  bluish-rtnl  with  a  considerable  tendencv  to  caseation'and 
n.crosis.  Miliary  tubercles  of  the  skin  may  l)e  seen  in  some  cases  of 
^'•■neraiized  tuberculosis,  and  localized  tuberculous  wartv  growths  may 
orcur  on  the  hands  as  a  result  of  a  "  jwst-mortem  wound." 

Syphilid.     Hie  chancre  is  found  most  frequently  upon  the  genitals 
l)iit  may  occur  in  many  other  regions,  and  is  usually  single     After 
an  incubation  jjeriod  suitecl  to  the  relatively  low  grade  of  virulence  of 
the  spinjchete.  a  sharply  defined,  painless,  small,  hard  nodule  is  found 
with  a  deeply  lying  base  of  firm  tissue  which  extends  outward  on  all' 
mM.s  beyond  the  actual  nodule.     Microscopically  the  infiltration  of 
I'  iikocytes  and  plasma  cells  in  the  perivascular  regions  is  very  marked 
as  IS  the  proliferation  of  the  fixed  tissues  which  gives  hardness  to  the 
'iia>s      ihe  manifestations  of  syphilis  in  the  form  of  efflorescences  on 
tlif  skin  are  very  various;  the  simplest  is  the  erythema  syphiUtica  or 
"'a' iihir  syphihde,  which  is  seen  as  red.  ill-defined  areas  of  varying 
^1/'   tending  to  apjiear  on  the  trunk  and  t'       >.xor  surfaces     They 
I'l.iv  remain  for  a  considerable  time  ami  fack.  leaving  a  temporarv 
'"'wnish  pigmentation.    The  papular  syphilide  may  show  itself  in  the 
""■l>t  nf  an  area  of  the  erythema  as  well-defined  brownish-red  papules 
""  Mif  skin  dry  and  on  moist  areas  such  as  mucous  surfaces,  exuberant' 
j"  ;  t,  and  tending  to  ulceration.     The  mucous  plaques  of  the  mucos^ 
"    ng  to  tins  order,  but  the  rapidity  with  wl  ich  they  break  .lown 
i<    I-  to  thcr  appearing  as  flattish  ulcers  covered  by  grey  debris     The 
I'     nl.s  muy  hecome  infected  and  give  oritrin  to  pustules,  which  again 
"     me  scabbed.     A  combination  of  considerable  proliferation  with 

'at i.)n  and  scabbing  gives  rise  to  the  peculiar  structure  of  concentric 
'      ^  called  rapia.    Actual  gummas  may  occur  in  the  skin,  but  more 


h 


'I 


i!    I 


I 


ro2 


THK  MOTOH    rV/>  TE(.i  ^tESTAHY  SYSTEMS 


i.i 


u.  - 


often  Im-Ioiik  originally  to  the  mikIitI;  iiig  tissue  uiid  involve  the 
later.  The  true  >;umnias  of  the  sk  '  show  as  Hat  hani  areas,  liki 
hase  of  a  ehancre,  t»'ii«iiti>;  t..  iileenui  iii'l  form  '  |)iiiiche<l-out"  ill 
III  all  these  ulctrative  lesion^,  the  healiiiR  is  attended  by  a  m« 
degree  of  searriiiK. 

Lepr*  (I>e|)r<)sy)."  This  is  seen  in  the  skin  as  nodules  of  prolifer 
tissue  <()ntaii)iiig  the  causative  1..'  'Mi,  o<-    .s  yellowish-n"*!  or  bi 
sj)ots  on  the  skin  or  mucosie,  with  i  .    rdaiuMatory  iofiltration.    A 
scarifiratioii  yields  a  Huiil  in  wliic''  tin     tuir  cteristie  bacilli  are  rei 
found.    (Wyatt  .lohnstoii.) 

Other  Granulomas,  Blastomyco''-,  D«r-.ia'omycos«s,  Etc.  Glai 
oecurs  in  the  skin  as  an  acute  inflai  unati'  u  dii"  to  infeetion  of  u  *■« 
or  other  solution  of  continuity  and  actinonyosis  usui.'My  us  a  se<;on 
prcK-ess,  apjM'ariii};  as  a  clironic  u'l  ■  i  itiun  t.-.  o*  er^;r<iwth;  a  lesic 
like  nature  is  Madura  foot,  of  whi'  the  ransative  iii,'<-nt  is  .1/ (/<•(■ 
imli.t.  .Vniong  the  prolifi  rativc  (and  secoii.I  .il.  ulct  r;iti\()  k'sioi 
this  nature,  must  Ik*  considtTed  that  formed  l.y  t-iastonivees,  blast 
cosis.  litre  a  g"iieral  infection  of  the  bcKly  rnav  (Kctir,  but  mori' 
(piently  a  distinctly  hypertrophic,  -^'larply  definetl,  w  a n  ,  cru>ted  gn 
is  found.  Heginiiiiig  as  a  j)apule,  the  mass  is  distiii  ly  of  inrianiiiui 
tyiM',  and  in  the  later,  larger  Itsions  minute  abM-esses  oetnir  in 
substance;  in  these  abscesses,  as  elsewhere,  the  ycast-like  organism 
be  found. 

Favus  is  due  to  Arlicrion  Srhd"li  iiiii,  which  >u<ceeds  in  obtaii 
footing  in  the  hair  follicles  and  setting  u]i  a  low-gr.ide  inflainnt, 
with  tile  formation  of  a  yellowi-h  cupjM'd  disk  coiuj-'ised  of  iH 
which  lies  upon  a  slightly  inflamed  area  «>f  skin.  Ring  worm  nia 
caused  by  more  than  one  mould,  most  comnHuily  by  the  Trichnph 
and  is  known  as  tinea.  It  may  affect  the  scalp  (T.  tonsurans),  the  i 
less  skin  (T.  circinata),  the  l>card  ^T.  sycosis,  often  .icutc  by  rcaso 
eoc'.'ie  infection),  and  the  covered  parts  of  the  skin  i"^.  versicolor), 
latter  is  often  -all' "  pityriasis,  and  is  relativelv  nnirnpo    mf. 

\'III.  Inflamm&i..oas  of  the  Skin  Caused  by  Animal  Parasites. 

The  lc->ions  caused  by  animal  parasites  arc  often  of  themsihcs  (| 
inconsideralilc  but  are  nearly  always  coini)Iicatcd  by  the  fact  i 
the  itching  Mt  up  lea<ls  to  scratching  and  tin.  to  secondary  iiiH 
mati''.i  of  \arious  types.  Most  important  of  tiiese  parasitic  Its 
is  scabies,  set  up  by  the  Ai-nrun  xctthni,  wliicli  burrows  into  tht 
in  a  direction  soint  uiiat  parallel  to  tin  surface,  and  lieposits  egi; 
the  burrow  thus  made.  The  constant  and  long  continued  rrit.i 
by  scratching  as  well  as  by  the  insect,  may  liaf!  to  a  general  f  h.icki ! 
anil  pigmentatiim  of  the  skin  (vagabond's  disease).  Pediculosis  is 
term  applied  to  the  lesions  causetl  ,.y  the  presence  of  lice 
kinils;  fleas  ami  bctlbugs  also  cause  lesiini^  that  are  usually 
Myiasis  is  the  term  ajipiied  to  the  deposit  of  the  eggs  of 
iOijitera)  in  the  iieighborhot)d  of  ti:  irious  orifices  of  ■ 
to  the  ensuing  inflamination. 


!  M  in 


I  HE  SKt.\~ArH*'l'Hy 


"03 


Motluscam  contafiosiaa,  rt-ferrecl  •..♦■Wwhrn-  if ..  25N     -^ ii hlastoraatoid 

ill',  inaiiu'iiratnl,  ainir  'iiijj  to  m)ii  »•  autliur-  l)V  a  .Kruliiim.  The 
guinea-worm  {I'ilnrin  ini>  nmiM\  aiul  tin-  chigoi)  arc  also  examples  of 
piir.i  ite>  tliat  hiirmw  in     ,<  skic. 

BHnssiTe  Chanfes  Atroi^y  .troj>'  f  t^  skin  o<(urs  in 
the  old,  a  general  pron^  of  fii   .nnig,  t!  Uf.  |jt«<-^>niinj;  narrower, 

tlji-  epidermis  dry,  and  the  siilxii  ,iw)Ur  ai  >ii  L'reiitl;  ■d)sorh<d  as  to 
iliow  thf  ?ikiii  to  wririkle  \  loejii  i.ro€cs:>  f  ai.ophy  is  noti.  able  in 
t'iif  skin  as  the  so-iailed  Uaege  albacantM,  ^    iieli  ure  wliitish         ilv«'ry 

liiii-    tfi.    result  of  ■'  I'rev  ions  distt  iis )t   thi     kin.     Tht-v  arc    ren 

in»t    niiinionly  in  tu.   breu  '  ,  tlie        lome;    ;ii        lie  '  and  frc- 

umiith    follow  prc^'  aiiey,  t  iough     '     tehini;    'f  tV  irom  any 

otiier  eaii-*e  v  ill  suffice     t  t!    ir  priHlucrHi. 

Necrosia,— \»  Tosis  ol    tlu     -kin   oei !    i  ae< 

i'l>i  r  tlssu«>s  II.  htnlsop    .  ai      uUrrs    if  of 
.  iiii;riiie  and  cirt  u^  ttorx  liistii;    .luces  su(  ii     -  , 

Pigmentation. — ^  ariation-  in  'le  pigmeiitii.if 
wiii>i(lered  in  this  i  lass.  '*^(  <\m\>\ 
iiiTriial  pigment  of  t  ••  n  -  -,  i!  «-oriui 
;iiiil  l)ile  pigments,  ii  V.\)  i\w^-  M>»it  of 
'I'll  ciiiigenital  lack  .igmi  ,.  1  tat* 
I'cwlicrf. 

Vitiligo    r  Le>;^i(oderma  i:-  1 1<    ali:-  <  1 1 

liie  normal  p..  icnt,  see    mthi  <lar 
w  liicli  irregular  anas  of  «  hit^-  skin,  on  v 

I 


fl)  I. 

th. 

-•te.! 


>ai    •'        lecrosis  of 

wi-  -veil  a  in 

«»'  ase. 

.»re  Se 

ease  i  le 

;H.arance  of  1.  ^| 
ngested  pigments 


i.g  reference  lias  l>een  made 


iip|.(arin  various  J  mrt-^i.      ■el:>od> 
ii'.rnial  pu'iuent  k  -  en  .        rc-^ult 
'il  <'liilii!i(MMl,  a-  ilsi    in  pigment  -da 
"     i<rt  :|  with  ihe  iriiiital  fu 
diabete       iifter  stmbum,  after 
in  hem    hromatosia,  ai  '   in  jauncb- 
'  u  rei.  •    IsevMn  r.'    as  has 

•<■  F>.  '■^'         X&ntiielasr  .  is  an 
•'-'  t'         aU         'lit        lid. 


trance  or  congenital  alxnce 

)fti  iier  tliari  the  white  races,  by 

ieh  the  hair  also  is  unpiiriuented, 

use  is  unknown.    Increase  of  the 

etioii  of  suidight  in  the  freckles 

m%^  uaN   rts,  in  chloasma,  obscurely 

in  A     .son's  disease,  in  "bronse- 

linn  <     physical  counterirritants, 

V.     Most,  if  not  all,  of  these  have 

'he  general  subject  of  pigmentaticm 

-iniderstood  yellowish  pigmentation 


ProfT  .-.K;?e  Cba,!  ses.  Ve  have  already  touched  upon  certain  con- 
!  ns  .  ;.!.riz«,  'v  niarkwl  n  i)erplasia  of  the  epidet  i  n . ;  a  local 
ixrplasia  in;i  ai  i  Ih'  a<  Irtil  ;is  the  result  of  chronic  irritation 
■f  he  fami'iai  •:al1  -  ,)n  the  palm  or  sole,  and  the 
ihe  result  ol  it  slight  irritati(»n  there  develops 

a  1  iiii  reaseil  d.  unent  of  layers  of  keratinized  epi- 

•h  may  be  local,  as  in  the  abovc-mentione<l  cases,  or  may 
•  lized  as  in  the  marked  thickening  that  occurs  involving 
■f  those  accustomed  to  walk  barefoot.     A  condition  that 
l)e  regarded  as  of  congenital  origin  is  the  dcNcIopment 
aorns,  which  in  some  cases  have  been  reported  as  attaining 
iry  size,  a  foot  or  more  'n  length.     The  horn  is  generally 
I  exhibits  a  base  showing  active  growth  of  the  deeper  layers 


'n   'he  ea.'^f 
rn.     Here  , 
'lii-kening, 
ium.     Si'i 
iiore  get 

•       wi„.le.. 
-t  |...^ 
■■ilttuei 


I 


d 


f  I 


3 

If 


i; 

I 


iM 


t ' 


r()4 


THE  MOrOR  A.XD  TKdUMKSTAHY  SYSTEMS 


of  the  epidermis  and  overlying  tliis  is  a  succession  of  closely  par 
adherent  lavers  of  keratinized  cells.  Diffuse  li.cal  thickening  of 
skin  may  further  result  from  chronic  inflammation,  c.  g.,  eczema,  syp 
itic  lesions,  etc.  Warts  or  verruca  are  localized  hyperplasias  of 
epidermis,  and  when  of  large  size  show  a  coincident  overgrowth  of 
underlving  cutis,  presenting  a  definite  stalk,  and  sometimes  hecon 
definitelv  papillomatous.  The  remarkable  point  regarding  then 
that  after  being  present  for  years  they  may  spontaneously  undc 
atrophy  and  disappear.  There  is  some  indication  that  they  an 
infective  origin,  it  having  been  observed  that  they  may  be  conve 

by  contact.  .       ,  .  ,  ^i    ^i 

A  condition  or  group  of  conditions  in  which  apparently  the  prim 
disturbance  involves  the  dermis  and  subdermal  tissues  with  second 
epidermal  hvperplasia  is  seen  in  elephantiasis.  As  already  indici 
there  are  several  forms  of  this;  one  group  is  congenital,  and  is  comi 
able  with  maeroglossia  an<l  macrocheilia.  The  most  common  forr 
encountered  in  tropical  regions  and  is  filarial  in  origin  (elephanti 
arabum)  Other  causes,  as  Ivmphatic  obstruction,  lead  to  very  snr 
api)earances;  such  are  obliteration  of  the  main  lymph  channels  ol 
extremity  through  new  growth  or  chronic  fibroid  lymphadeniti> 
Ivmphaiigitis;  while  lastly,  syphilitic  and  other  chronic  inflammati 
(if  the  skin  bv  causing  a  chronic  n>dema,  favor  the  setting-up  of  r 
orders  of  this  condition.  In  all  these  states,  it  appears  that  we  ( 
with  a  relative  or  actual  lymph  stasis,  leading  in  the  first  plac« 
enlargement  of  the  part,  and  secondarily  to  a  diffuse  connective  ti: 
hyperplasia.  Due  to  the  distension,  of  nuxlerate  grade,  of 
underlving  tissues,  the  epidermis  tends  to  hypertrophy,  forming  i1 
into  f(ilds  and  sometimes  more  warty  and  ncKlular  overgrowths. 
coiKlition  most  fretpiently  presents  itself  in  one  or  both  of  the  ki 
extremities  or  in  the  scrotum,  the  latter  being  apt  to  attain  a  colo 
size,  extending  below  the  knees. 

A  milder  tvi)c  of  thickening  of  the  skin  with  primary  involveii 
(.f  the  dermis  mav  artect  considerable  areas  of  the  limbs  or  trunk 
is  H-en  in  the  group  of  conditions  known  as  scleroedema,  sclerodei 
and  sclerema.  Of  the  -  the  first  manifests  itself  in  long-contin 
anasarca;  it  is  allied  to  the  condition  seen  in  myxcedema,  there  hen 
brawnv  hardness  of  the  affected  part,  witli.  however,  little  chang 
the  overlving  epidermis.  In  scleroderma  a  similar  induration  I 
continued",  is  followed  by  distinct  hypertrophy  iiuolving  not  only 
dermis  but  also  the  epi<lermis.  An  associated  state  is  seen  in  derm 
myositis  in  which  the  underlying  muscles  bect)ine  intensely  lianlc 
and  rigid,  and  the  skin  above  them  appears  as  though  adherent  im 
capable  of  curtailed  movement.  Little  is  known  regarding  the  ci 
of  either  of  these  condititms.  Neurosis  has  been  suggested,  a  condu 
parallel  to  that  of  angioneurotic  (wlema.  In  dermfttomynsitis 
muscle  at  first  shows  little  change  beyond  congestion  and  o<le 
in  both  the  ajjparent  primary  hyiiertrophy  is  apt  to  be  follov\ed 


THE  SKIS— TUMORS 


705 


.itrophic  changes.  Sclerema  is  a  congenital  condition  or  develops  in 
infancy,  and  is  characterized  by  a  diffuse  thickening  and  induration 
of  the  cutaneous  tissues  without  recognizable  anatomical  changes. 
Ccrinan  authorities  have  called  attention  to  the  fact  that  there  is  here 
ii  iiiodification  in  the  corajMisition  of  the  fat,  in  the  direction  of  increased 
IMTci'iitaKc  of  the  less  soluble  palmitin  and  stearin  fats  whereby,  in 
|)lii(c  of  being  fluid,  the  fat  within  the  fat  cells  is  solid. 

Tumors  and  Tumor-like  Growths.— We  have  already  referred  (p.  259) 
t(i  the  development  of  cutaneous  horn?  which  are  not  strictly  tumors, 
Imt  muiischarged  keratinized  cells:  to  keloid  (p.  231),  in  which  we  have 
a  striking  overgrowth  of  the  subcutaneous  connective  tissue  secondary  to 
irritation,  but  at  the  same  time  due  to  congenital  hyperplastic  tendency 
nil  tiu-  part  of  these  tissues:  to  multiple  cutaneous  fibromas  (neurino- 
matosis)  (p.  247),  flue  to  overgrowth  primarily  of  cells  of  the  sheath  of 
Schwann  around  filaments  of  the  cutaneous  nerves:  to  diffuse  lipoma- 
tosis, or  blastomatoid  hyperplasia  of  the  subcutaneous  fat:  to  the  allied 
KMiilition  of  adiposis  dolorosa  and  also  to  Xanthoma  (p.  233).  There 
nrriaiii  certain  overgrowths  which  fleserve  more  particular  notice. 

True  fibroma  may  be  present,  most  often  in  the  form  of  solitary  tumors 
vvliicli  may  attain  considerable  size  mkI  may  be  either  hard  or  soft. 
Myxoma,  chondroma,  and  osteoma  are  rare.  We  have  encountered  a 
iiuilti|)lc  cutaneous  formation  of  small  chondroma •  uus  plaques  in  the 
>kiii  ,.t'  the  legs,  evidently  metaplastic.  The  skin  is,  however,  a  favorite 
-ini  lor  the  development  of  lipomas,  more  espe.'ially  in  the  ^liouider 
ri-ii)ii.  These  solitary  lipomas  have  a  lobulated  structure  and  may 
attain  considerable  size.  Several  cases  of  multiple  small  myomas  are 
'III  ncord,  and  '-ome  of  solitary  myomas,  of  small  size,  originating  evi- 
'li  iitly  from  the  arrectores  pilorum,  and  from  the  muscles  of  the  sweat 
ulaiicls, 

I  inlcr  the  heading  of  navi  ('or  birthmarks)  anil  moles  are  to  be  grouped 
a  miinlxT  of  ditlVrent  conditions.  The  hairy  mole  is  a  patch  of  normal 
^kiii  f;i\ing  origin  to  large,  coarse  hairs  in  a  region  normally  hairless, 
I  n<|ii,.ntly  associated  with  this  there  is  marked  pigmentation  and 

^ '■  hypcrtropliy  of  tive  skin.     A  section  through  such  a  mole  shows 

In  .|neiitl,\-  a  more  vascular  condition  than  normal,  with,  in  addition, 
i'  I'i'iiii'iiiiced  collection  of  chromatophores  or  pigment  cells  around  the 
•  1^.    The  nevus  is  of  larger  size  and  comprises  a  variety  of  condi- 
t'n.ni  the  soft,  warty  masses,  showing  abundant  cells,  to  states  of 

' "^   nnd    widespread    cavernous   dilatation    of   the   superficial 

'Is  whicli  may  involve  the  whole  of  one  side  of  the  face,  or,  as  we 

■  Mcii,  tiic  whole  head,  or,  again,  a  large  portion  of  the  trunk.  The 
i<  I,  eellular  forms,  like  certain  moles,  show  masses  of  somewhat 

■  il  i>r  piilygonal  cells  surrounding  somewhat  enlarged  vessels. 
'"•  larger,  the  dilatwl  vessels  preilominate  and  cause  a  striking 
li  "r  reddish  cajoratioii  of  the  affected  area  ("strawberry  mark"). 

'  'Militiiin  is  most  often  what  has  been  termed  cavemoma,  or  cavern- 
'ii^onia,  but  occasionally  we  meet  with  not  merely  this  dilated 


\  I' 

tiu 

I'hi 

\i 

ll.l 

-|i| 

ml 
111 


;r-" 

i 

!:S    ' 

roG 


THE  MOTOR  AXD  TKOUMESTARY  SYSTEMS 


oondition  liut  a  true  blastomatons  prolifcratiiif;  angioma  with  jjroprvs: 
pniwth  into  tho  surnniiidiiijr  tissue.  So,  also,  at  tiiin-s  wt-  t'iu'(»\ij 
conditions  of  lymphangiectasis  wliicii  may  wirp,  and  true  cutanc 
lymphangiomas,  or  lymphangio-endotheliomas.  Any  of  the  aho\e  i 
neetive-tissue  tiniiors  may  ^ive  rise  to  sarcoma  or  to  sarcomat 
developments.  \t  the  same  time  i)rimar,\-  s^^eoma  does  occur,  roui 
spindle-,  or  mixed-ceiled  together  with  a  remarkable  form  of  difl 
sarcomatosis  of  the  skin  wliich  may  involve  larne  areas  (mycosis 
(oides).  The  chara<ter  of  this  jjrowth,  however,  makes  one  stroi 
susi)ect  that  here  we  may  deal  with  a  si)readinf,'  inflammatory  condit 

FiQ.  304 


fiection  from  a  ■  aw  uf  lii'niaintiiinia  siiiiplii,  exhibiting  progressive  enlHrgcment  rhiI  eileusii 

iBorrmann  ) 

A  not  uncommon  form  of  malignant  tumor  is  the  melanoma  or  chro 
tophoroma.  We  hesitate  to  sive  this  its  usual  name  of  melanotic 
coma,  inasmuch  as  there  is  still  considerable  discussion  as  to  wiie 
this  he  of  epithelial  or  perithelial  oripn.  These  tumors  orijiinate  iisii 
from  a  pigmented  nevus  or  mole,  and  in  these  from  the  large  polvg' 
cells  or  chromatophores  situated  immediately  around  the  vcsmU. 
have  repeatedly  called  attention  to  the  abundant  metastases  \vl 
they  are  liable  to  set  uf). 

Carcinoma.-  The  malignant  epithelial  tumor  of  the  skin  is  natur 
the  squamous-ceiled  carcinoma  (epithelioma),  but  of  this  two  foiii)-* 


tsjm 


JUBPJJIMJ.  ^Ji 


THE  SKIS—EI'I TUELIOMA— CYSTS 


it  anil  rxtcusion. 


707 


5  t 


r.c.)>;iiizal)le:  tlie  one,  the  squamous  epithelioma  proper,  sueli  as  is 
s.rn  on  the  hp,  serotum,  or  penis,  is  eharaeterized  bv  lar^e,  mo<lerateIv 
course,  fiiifjer-like  proeesses  (lipi)inK  down  into  the'underlvinjj  tissues 
l)n  ^entniK  well-marked  epithelial  pearls,  and  with  its  deep  infiltrative 
IMAvers.  mamfestinf:  a  marked  tendency  to  develop  metastases  in  the 
nn-lihorniK  lymph  nodes.     This  may  oriRinate  either  from  the  cutis 
l-ropcr  or  from  the  hair  follicl(.s  or  sebaceous  glands  and  shows  a  marked 
ttn.l.i.cy  toward  ulceration.     The  other  form,  the  rodent  ulcer,  i)resents 
itM'  f  most  commonly  on  the  upper  i)art  (.f  the  face,  where  it  is  eharacter- 
iz.d  hy  slow  growth,  extending  sometimes  over  vears,  shallow  and  drv 
iilcrratK.n,  fibrosis  and  cicatrization  in  certain  parts  with  sh.w  exten'- 
M.m  i.iid  eating  away  of  the  superficial  tissues,  and  often  a  superficial 
uri.iklmgby  reason  of  the  contraction  of  the  fibrous  tissue.  A  remarkable 
tad  IS  that  only  late  in  its  course,  when  there  has  been  nmch  erosion 
(lo.s  this  show  deep  infiltration   and  the   formation   of  metastases' 
Mi<  mscopically  the  c;ll  columns  are  small,  irregular,  with  absence  of 
cpitli.hal  pearls.     The  simpler  t>pe  of  cell  seen  in  this  form  with  its 
( .piirture  from  the  typical  prickle-celled  type,  led  Krompecher  to  include 
this  Miiiong  the  basal-celle<l  carcinomas,  on  the  unfounded  supi)osition 
that  It  originates  from  the  deeper  Malpighian  laxer  rather  than  from 
th.'  fiilly   ormed  epithelial  <rlls.     There  is  no  evi.lence  for  this  assump- 
tion, hut  by  analogy  we  must  say  t!  at  it  is  composed  of  cells  that  have 
iiiHlcrgoiu'  a  greater  anaplasia  and  nave  lost  the  capacitv  to  develop 
th.'  im.r..  ditVerentiated  ceP      The  observations  of  Wolbach  upon  the 
<  loM  ly  allied  .r-ray  cancer  of  the  extremities  and  other  regions,  affords 
It  •<(vins  to  us,  a  possible  explanation  for  the  absence  of  metastases  iii 
this  torn,.  VIZ    in  the  hit.,  r  'orm  it  is  evident  that  a  fibrosis  with  con- 
'l<Ms|ti,.i.  ot  the dernns  precedes  the  cancerous  change  in  the et)ithelium 
aiM  III  tins  way,  by  the  density  of  the  underlying  connective  tissue' 
altonl.  a  barrier  against  the  easy  i)enetratioii   of  the  cells  into  the 
|lif|«T  lymphatics. 

Sn„n(lary  carcinoma  of  the  skin  is  not  very  ccmimon;  it  is  seen  most 
"tt.  inn  c.nnection  with  mammary  cancer,  one  form  of  which  shows  a 
l>''iih;,r  tendency  to  spread  along  the  cutaneous  lvmi)hatics,  giving 
FM'  t,,  til,,  so-called  cancer  en  cuirasse. 

Cysts.  Retention  cysts  may  show  themselves  in  connection  with  the 
Miiar, .„w  glands,  (.tten  secondary  to  a  condition  of  seborrhoea  or  hvper- 
•■'■'•n  tH,M.  resuhuig  in  the  pr  .i.-ti„n  of  wen*  ....  the  scalp  or  sebaceous 
cy  s  cMwhere.  Uetentio-  .  -.  may  als,>  attect  the  sud„rii,arous 
i  :  ,  "'"'"  '."  '"^^■!"K  '>.yi  "  -tion,  res„lti..g  i..  miliaria,  mi..ute, 
.i.,,r  -..we  vesicles  immediau  .    under.ieath  the  upoer  lavers  of  the 

cnln  *  !',V',"r""'"*''*"  ''''  '"">■  ""'"tion  the  allied  condition  of 
comedones  (    b  ackheads  '),  a  c...,dition  .lue  to  the  bloekh.g  of  the  ducts 

'       -  oils  gja.ids  by  plugs  of  sebum  and  .lesquamated  cells.     Thev 

■"    I-  •  .u.nnio.iiy  seen  upo..  the  no.se  a..d  chin.     Yet  a.iother  form 

'  'leserves   .nc.t.o.i,  the  implantation  cyst,  bro.ight  about  bv 

"  -  natic  torcing  of  cells  from  the  <lecper  epidermal  lavers  into  the 


i  i 

1 

1  ' 

M     !'■ 

1 


708 


THE  MOTOR  AND  TEGUMENTARY  SYSTEMS 


dermis  (see  p.  293),  an.1  the  rarer  true  cutaneous  dermoid  due  ti)  f 
embryonic  inclusion  of  epithelial  tissues  in  the  deeper  layers  durii 
the  process  of  closun;  of  various  fissures. 


n- 1 


THE  HAIB 

Certain  diseased  states  of  the  hair  call  for  notice.    There  may  1 

excessive  prtMluction  of  hair  (hyperte.chosis)  either  over  tlie  great 

part  of  the  bixlv  or  in  particular  regions,  notably  over  the  site  of  i 

occult  spina  bifida  or,  in  the  female,  on  the  chin  and  lips.     Absence 

hair  from  regions  where  normally  it  should  exist  is  spoken  of  as  alopeci 

This  mav  be  congenital,  and  then  either  universal,  or  as  on  the  moi 

in  the  axilla,  and  on  the  face,  associated  with  a  lack  of  developrae 

of  the  secondary  sexual  characters;  or  a  senile  change,  or  prematui 

supposedly  a  trophoneurosis.     Apart  from  this,  it  may  be  a  mauifesi 

tion  of  a  ilistinctly  local  trophoneurosis,  round  or  oval  an  as  of  the  sc£ 

being  affected  (alopecia  areata).    Similar  'cf-al  loss  of  hair  may  foll( 

the  growth  of  sundry  moulds,  e.  g.,  frirlwphyfon,  or  in  localized  mfta 

mations  or  after  infective  fevers.     Nutritional  changes  in  the  hair  i 

little  understocxl;  premature  whitening  (canities)  may  be  found  d 

to  arrested  development  of  pigment,  without  (.f  necessity  any  otl 

sign  of  defective  growth,  and  may  also  follow  severe  nervous  shock, 

continue*!  nervous  irritation  as  in  migraine  and  neuralgia;  somttm 

local  patches  of  canities  constitute  a  family  trait.    Other  disturban 

due  to  (l-fectivc  nutrition  -ro  splitting  of  the  hair,  clubbing  of  the  ( 

of  the  hair,  uneven  caliber  of  the  hair,  or  beading.     In  certam  of  i 

above-mentioned  parasitic  diseases,  the  defective  nutrition  of  the  li 

is  manifest  in  its  brittleness. 


THE  NAILS 

Abnormalities  of  the  nails  are  rare.  Hemorrhages  may  occur  in 
bed  of  the  nail  in  cases  of  malnutrition  combinwl  with  sudden  chan 
of  temperature.  Inflammation  may  attack  the  tissues  at  the  nwt  o\ 
nail  (onycUa)  or  at  the  edges  (paronychia)  leading  to  suppuration  i 
sometimes  exfoliation.  With  paronychia  the  relation  of  nail  and  ; 
part  may  be  altered  so  that  the  nail  jwiietrates  the  deeper  tissues  (ingr 
ing  toe-naU),  while  flecks  due  to  the  presence  of  air  between  the  la.\ 
of  the  nail  mav  appear  in  the  Iwxly  of  the  nail  (leukopathia),  or  a  tn 
verse  furrow  mav  mark  on  the  surface  the  date  of  a  past  acute  lUn 
both  of  these  being  evidences  of  temporary  malnutrition.  Ihe  n 
mav  grow  to  an  enormous  extent  (onychogryphosis)  with  great  dctoni 
in  shape,  in  this  comparable  to  the  development  of  cutaneous  l.o 
Parasitic  diseases  of  the  Am  (favus,  ring-worm)  ma>'  affect  the  i.i 
and  the  mycelial  threads  may  actually  penetrate  and  grow  witHui 
nail  substance. 


INDEX 


Abdominal  epigastric  hernia,  569 

fissure,  72 
Aberrant  mammary  gland,  666 

proiitate,  633 
Abiotrophy,  57,  299 

of  nerves,  478 
AI>ii<>rniaHtie8,  61 
of  defect,  70 
ill  excess,  61,  62 
inheritance  of,  57 
Abortion,  tubal,  666 
Abrin,  immunity  against,  154,  155 
Ab,si;(>3H,  126 

antemammary,  667 
of  brain,  488 
cold,  684 
of  liver,  575 
of  orbit,  517 
IK'rinephric,  617 
peritonsillar,  437 
pylephlebetic,  574 
repair  of,  126 
rptropharyngeal,  438 
retro-uterine,  661 
of  skin,  700 
'stitch-hole,"  89 
of  thymus,  472 
I  ubo-ovarian,  655 
Abxihite  immunity,  152 
AiM|iiiia,  179 

Aririliae  monstrosities,  63 
Aicioiie  bodies,  109 
A<iiiiimriii,  109 
Ai  hcinilroplasia,  678 
A(hiu.-.is,  104,  106,  109 

iif  blood  plasma,  359 
Ar„.<,f  skin,  700 
ro.-iacea,  700 
Aniiirrd  characters,  inheritance  of,  53 
liseases,  55 
iMimunity,  115,  116 
iiKHlifieations,  43 
A.'i   i.iii,  72,  485 
Ai     inenaly,  101 

:iiuitary  body  and,  493 
A '  •     Pin  vcosis  of  bone,  685 
I  brain,  490 
-1  kiilnry,  619 
'  larynx,  443 


Actinomycosis  of  liver,  583 

of  lungs,  465 

of  mouth,  525 

of  muscles,  675 

of  peritoneum,  566 

of  skin,  702 

of  spleen,  418 

of  stomach,  5S6 
Active  hyperemia,  337 
i  Activity.  lack  of,  as  cause  of  disease,  1 15 
Adaptation,  36,  40 

I         of  human  body  to  temperature,  77 
I  Adaptive  hypertrophy,  187 
I  Addison's  anemia,  360 
i         disease,  102,  422,  703 
Adenase,  107 
Adenin,  27,  107 
Adenocarcinoma  of  stomach,  539 

of  thyi  Ad  gland,  425 

of  uterus,  651 
Adenofibroma  of  ovary,  659 
Adenofibrosarcoma  of  mammary  gland, 

670 
Adenoids,  428,  440,  460 
Adenolipofibroma   of   mammary   gland, 

670 
Adenoma,  261 

of  adrenals,  422 

of  bladder,  627 

of  bronchi,  446 

of  kidney,  621 

of  larynx,  443 

of  liver,  589 

of  lungs,  465 

of  mammary  gland,  670 

of  nose,  430 

of  pancreas,  597 

of  parathyroids,  426 

of  stomach,  539 

of  thyroid  gland,  425 

of  uterine  ligaments,  662 

of  uterus,  651 
Adenomatosis,  262,  264 

of  mammary  gland,  668 
Adenomyoma  of  uterus,  243,  650 
Adeiiomyxosarcoma  of  mammary  gland, 

670 
Adherent  pericardium,  383 
Adhesive  otitis  media,  520 
Adiposis  dolorosa,  233,  705 
Adrenalin,  102 


^.i^-ikJa-^'* 


no 


ISDEX 


I 


N 


Ailn-imls,  421 

ahnorniiilitu'.s  of,  421 

accessory,  421 

iidciioniiiM  of,  422 

uiiciiiia  of,  422 

atrophy  of,  422 

carcinoma  of,  423 

cavitation  of,  422 

cortex  of,  overgrowth  of,  102 

cysts  of,  423 

degenerations  of,  422 

disJ'Jises  relatc<l  to,  102 

heinorrhatje  of,  422 

horstwhoe,  421 

hyperemia  of,  422 

hypernephroma  of,  423 

hyi)erplasia  of,  422 

hypoplasia  of,  421 

infarcts  of,  422 

hemorrhaKie,  344 

inflammation  of,  422 

Iyniphan(jiecta.ses  of,  423 

necrosis  of,  422 

neuromas  of,  422 

sarcomas  of,  423 

secretion  of,  102 

syphilis  of,  422 

tuberculosis  of,  422 

tumors  of,  275,  422 
Adrenin,  lIMt,  102 
Aerobes,  84 
Aerobic  bacteria,  84 
AeroKenic  pneumonia,  4r)l 

tuberculosis,  400 
AKglutination,  102 
Agglutinins,  102 
ARgressins,  160 
Agonal  inviigination  of  intestines,  546 

oedema  of  lungs,  447 
Agyria,  4Ht» 
Air  embolism,  352 

passages,  427 

sacs,  431 

changes  ii!  walls  of,   hindering 

aeration,  432 
collapse  of,  431 
distention  of,  431 
interstitial  deposits  in,  433 
obstruction  of,  431 

transmission  of  bacteria  by,  00 
Albinism,  47,  500,  005 
Albumin,  25 

Hence-Jones,  603 

egg,  25 

s<!rum,  25 

in  urine,  602 
Albuminoid  vegetable  jwisons,  immunity 

against,  154 
Albuminous  degeneration.     Hee  Cloudy 

swelling. 
Albuminuria,  603 

cve'ical,  603 
febrile,  151 
infectious,  603 


Albuminuria,  physiological,  603 

toxic,  t>03 
Albuminuric  neuroretinitis,  513 
Albumoses  in  urine,  25,  603 
Albumosuria,  autolysis  and,  1(X) 
Alcoholic  neuritis,  .507,  508 
Alcohols  in  cell,  33 
AlepjK)  button,  05 
Alexm,  164 

;  Alimentary  leukocytosis,  364 
i  Alkaptonuria,  lOH 
Allergy.    'S'     Anaphylaxis. 
Alloxuric  bfxlies,  107 
Alopecia,  areata,  708 
Altmann's  granules,  301,  365 
'  Aluminosis,  325 
I  Amastia,  t)66 
j  Amazia,  titiO 
Ambocei>tor,  164 
Amino-acids,  25 
Amitosis,  3H 

Amitotic  cell  division,  38 
Atnnion,  665 
Amniotic  fluid,  6t>5 
Amccbic  abscess  of  liver,  575 

colitis,  558 
I  Amphimixis,  46 
'  Amphoterisni  of  amino-acid,  25 
Amputation  neuroma,  108,  245,  500 
Amygdalitis,  437 
Amyloid,  34 
I         bodies  of  prostate,  321,  633 

degeneration,  3tKi,  307 
of  adrenals,  422 
I  of  lymph  nwles,  413 

I  of  mvocardium,  390 

i  of  heart,  "390 

i         inHltration  of  arteries,  401 
'  of  kidney,  620 

of  liver,  585 

of  pancreas,  597 

reactions,  308 
Aniyloidosis,  308 

Amyotrophic  lateral  sclerosis,  499 
Anadidvmus,  67 
Anaerobt!s,  84 
Aiiakatadidymus,  67 
Anaphase  of  mitosis,  40 
.Anaphylaxis,  117,  170 
.\naplasia,  203 

in  tumors,  285 
Anasarca,  336,  339,  366,  368,  CM 
Anemia,  339 

Addisonian,  300 

of  adrenals,  422 

a|)lastic,  361,  419 

of  bone  marrow,  419 

of  brain,  486 

collateral,  339 

of  intestines,  546 

of  kidney,  608 

of  lurvnx.  441 

ol  liver,  570 

of  mouth,  523 


ISDEX 


711 


Anoinia  of  musclos,  O73 
neurotonic,  3;jit 
of  pericardium,  ;{82 
of  peritoneum,  5t»2 
|)erni('iouM,  3Wt 
of  piu-arachnoid,  .'i()4 
of  placenta,  liM 
of  retina,  510 
secondary,  300 
of  tikin,  695 
of  spinal  cord,  4!)5 
splenic,  241,  415 
of  Ntomach,  533 
Anemic  infarct,  344 
Aiiencephaly,  7'2,  4S5,  493 
Aiic-itliesia,  479 
Aneurysm,  27S,  298,  407 
arteriovenous,  40S 
in  hrain,  4S8 
cirsoid,  278,  407 
dilatation,  407 
dissectinit,  407 
false,  408 
futiiform,  298,  407 
miliary,  408 
mycotic,  408 
saccular,  298,  407 
I  Taction,  408 
varicose,  408 
Aiiciirysinal  varix,  408 
An(;icctas(>s,  278 
Ahdiiia,  437 

linlovici,  528 
pectoris,  378 
\iiicent's,  439 
Aiiuiiima,  277 

<if  bladiler,  627 
of  l)ones,  ti89 
of  brain,  491 
of  ear,  521 
of  kidney,  621 
"f  mouth,  526 
of  muscles,  676 
of  orbit,  517 
of  peritoneum,  567 
of  placenta,  664 
"f  pliMira,  470 
of  skin.  705 
ol  iiinbilical  cord,  665 
ol  vulva.  641 
Aiimoiieurotic  (edema,  373 
Anions,  32 

Ankylosis  of  joints,  091 
Aiil,\  lostomum,  destruction  of  tissue  by, 

Anl-ii^cn,  65 

Arionuilies.    See  Abnormalities. 
\-i"pli.|c.^  mosquito,  malaria  and,  97 
AiiM!.li(liu|,„ia_  5()<j 

An.i.-liidism,  637 

.\ni.  ilfxion  of  uterus,  644,  645 

Ani. mammary  abscpjis,  667 

Ann  ,i:itai  diaease,  55 

Am,  -uterine  hcn<atoma,  661 


Anthracosis,  325,  412,  4.5!) 
AntilxHlies.  1.55,  172 
Antidiastatic  enzyme,  1.56 
Anti-<"nzymes,  1.55,  1.56 
.Vntiferment,  156 
Antinen,  10;j,  172 
Antlpepsin.  1.56 
AntiiM'ptic  ferment,  1.56 
Antiprecipitins,  H)2 
Antirennin,  156 
.4ntiricin,  155 

"Antispecific"  qualities,  inheritance  and 
57  ' 

Antitoxin,  1,55,  1.56 
Antitoxins,  pnKluclion  of,  157-160 

toxins  and,  15<i 
.Vntivciiins,  168 
.\nuria,  602 
Anus  uterinus,  644 
Aorta,  coarctation  of,  387 
Aortic  endocarditis,  394 
Aphtha-,  .524 
Aphthous  stomatitis,  ,524 
Apical  pneumonia,  455 
Aplastic  anemia,  3til,  419 
Apneumato.sis,  449 
Apoplexy,  354,  487 
.\ppfcndical  eoncrements,  315 
I         constipation,  543 
I  ApiK>ndicitis,  548,  555 

catarrhal,  simple,  557 
diffuse,  557 
(jangrenous,  5,58 
iwrforafive,  557 
Appendix  epiploica,  566 

vermiforinis,  function  of,  .541 

Appo.siti metastasis  and,  219 

Aque<jus  liumor,  516 
i  Arachnida-,  98,  100 
I  Arcus  senilis,  514 
I  .\ret>la,  carcinoma  of,  672 
i  Areolitis,  667 
Arjtyria,  325 
Arrhincephaly,  522 
Arrhythmia,  379 
.Vrscnic  c.-iters,  1.53 

neuritis,  508 
Arterial  thrombus,  349 
Arteries,  399 

abnormalities  of,  400 
anastomosin);,  340 
arterio-sclerosis  of,  401 
atrophy  of.  4!K» 
degeneration  of.  401 
hypertrophy  of,  409 
hypopla.sia  of,  400 
infiltration  of,  401 
inflammation  of,  400 
occlusion  of,  340 
syphilis  of,  400 
terminal,  340 
thrombo-sis  of.  100 
tumors  of,  409 
Arteritis,  4<H) 


I 


:!>  r  t 


If    : 

?,-* 


712 


INDEX 


Arteriosclerosis,  298,  402 
nodose,  402 
syphilitic,  403 
Arteriovenous  anfuirysm,  408 
Arthritis,  091 

deformans,  692 
pauperuin,  093 
purulent,  092 
serofibrofibrinous,  091 
serous,  091 
suppurative,  091 
Asearis  luinbricoides  in  liver,  590 
Ascites,  339,  360 
chyliform,  370 
chylous,  370 
pseudochylous,  370 
Aspergillus  of  lungs,  405 
Aspermia,  637 
Asphyxia,  109,  430 
Aspiration  pneumonia,  455 
Aster,  40 

Asthenic  fever,  150 
Asthma,  429 
Atavism,  48,  50 
Ataxia,  Friedreich's,  498,  501 

locomotor,  500 
Atelectasis,  431,  449 
impression,  450 
Atheromatous  embolus,  352 

ulcer,  402 
Atherosclerosis.    See  Arteriosclerosis. 
Atherosis.    See  Arteriosclerosis. 
Atmospheric  pressure  as  cause  of  disease, 

77 
Atonic  constipation,  542 
Atresia  ani,  74,  645 
of  gall  duct,  591 
of  intestines,  544 
of  larynx,  440,  444 
recti,  545 
of  vagina,  642 
Atrophic  gastritis,  536 
pharyngitis,  439 
rhinitis,  435 
Atrophy,  297 

of  adrenals,  422 
of  arteries,  400 
of  bladder,  620 
of  bono,  685 
of  brwn,  4'M) 
brown,  of  heart,  388 

of  Uver,  580 
of  drum  membrane  of  ear,  520 
of  joints,  694 
of  kidney,  619 
of  larynx,  443 
of  Uver,  574,  583 
of  lymph  nodes,  413 
of  mammarj-  gland,  067 
from  malnutrition,  297 
of  muscles,  075 
of  myocardium,  388 
of  nerves,  478 
of  ovary,  666 


Atrophy  from  overwork,  297 
of  pericardium,  384 
progressive  muscular,  499,  675 
of  prostate,  C>4 
reversionary,  J03 
senile,  297 
serous,  306 
of  fat,  298 
of  pericardium,  384 
of  skin,  703 
of  spleen,  418 
of  testes,  039 
of  thymus,  472 
of  thyroid  gland,  424 
of  uterus,  649 
of  vulva,  641 
Auditory    meatus,    external.      iSee   Kai 

external. 
Aural  polyps  in  otitis  media,  620 
Auricle  of  ear.    See  Ear. 

of  heart,  371 
Auriculoventricular  node,  377 
I         valves  of  heart,  373 
Autochthonous  blastomas,  223 
i  Auto-intoxication,  79 
Autolysin,  103 
!  Autolysis^  105 

I  Autononuc  nervous  system,  475 
■  Autonomous  tumors,  207 
Autoplastic  transplantation,  199 
AuxeticB,  201 
Axone.  473 

aliiotrophy  of,  478 
degeneration  of,  478 
disuse  atrophy  of,  478 
i         pathological  changes  in,  477 
regeneration  of,  478 


Bacillary  colitis,  epidemic,  558,  559 
I  Bacilli,  84 

i  Bacillus  coli,  constipation  and,  HI 
diphtherite,  86,  438 
fuaiformis,  439 
typhosus,  90,  121 
"Hacoi   ■  spleen,  308,  418 
Bacteria,  action  of  gastrin  jaice  on, 
of  leukocytes  on,  87 
of  surface  washing  on,  80 
aSrobic,  84 
in  bladder,  626 
as  cause  of  disease,  84 
damage  of  cells  by,  grades  of,  121) 
development  of  ptomaines  and,  1 H 
ectotoxic,  85 
endotoxic,  85 
entrance  of,  into  body,  90 

physical  hindrance  to,  in  resp 

ratory  tract,  87 
through  genital  passage.",  '.'0 
intestinal  tract,  90 
lymph  nodes,  87,  91 


,86 


INDEX 


713 


Bacteria,  entrance  of,  through  placenta, 

ao 

respiratorj-  tract,  90 
skin,  90 
to  tissues,  86 

enzymes  of,  84 

exaltation  of  virulence  of,  170 

intestinal,  85 

passage  of,  through  body,  91 

pathogenic,  85 

phagocytosis  and,  124 

putrefactive,  85 

saprophytic,  85 

temperature  limits  of,  84 

toxins  of,  84,  85 

transmission  of,  by  air,  90 
by  direct  contact,  90 
by  f:/mitC8,  90 
by  insects,  90 

virulence  of,  91 
iiucterial  embolus,  353 

intoxication,  85 
liuotericr.iiii,  145,  629 
Hacterifii'lal  power  of  blood,  88 

of  mucus,  86 
H;ii;tcriolysins,  165,  166 
li;ictrriolysi8,  165,  166 
Hulnnitis,  630 
halaiitidium  coli,  97 
HaLinoposthitis,  630 
i^all  thrombus,  348 
li.iiiti's  disease,  241,  579 
Harlow's  disease,  688 
Basiil-celled  carcinoma,  264,  270 
li^ksiilow's   disease.     See   Exophthalmic 

Koitre. 
Ikilsore,  76 

HcmoJones'  albumin,  603 
H-o\ybutyric  acid,  109 
Ifircirnuate  uterus,  644 
Hile  i-ysts  of  Uver,  590 

ducts,  591 

tuberculosis  of,  682 

«ravcl,  319 

ill  peritoneum,  566 
Hilhurzia  hematobium,  260,  620 
liilliarziasis,  260 
H'liary  culcuH,  318 

•  irrliosis,  579 
liiliniiiin,  318 
Hilivi  nlin,  318 
liinnccrosis,  326 
■-  'plKTC,  24 

ilioric  molecule  of  cell,  24,  27 
■I  htsja,  35 
i      litiiarks,  278 
I'  'ii  palsies,  61 
l'ir!li>.  multiple,  64 
Hlill.-r,  024 

iliiiormal  contents  in,  626 

■  Ispnceof,  624 

vicnoma  of,  627 

'  iUKjiiia  of,  627 
iiiimaliesof,  624 


Bladder,  atrophy  of,  626 

bacteria  in,  626 

bilharzia  hematobium  in,  626 

carcinoma  of,  627 

ectopia  of,  625 

extrophy  of,  624 

fibroma  of,  627 

hyperemia  of,  625 

hypertrophy  of,  626 

inflammation  of,  625 

myoma  of,  627 

papilloma  of,  261,  627 

parasites  in,  t)26 

sarcoma  of,  627 

septa  of,  624 

syphilis  of,  626 

tuberculosis  of,  626 

tumors  of,  6''7 
Blastomas,  213 

atypical,  237 

autochthonous,  223 

heterochthonous,  223 

multicentric,  219 

pleuricentric,  219 

teratogenous,  211,  223 

typical,  237 

unicentric,  219 
Blastomatoid,  228 
Blastomatous  papillomas,  260 
Blastomycetes.    See  Yeasts. 
Blastomycosis  of  skin,  702 
Blended  character,  48 

inheritance,  48 
"Blighted  ovum,"  68 
Blood,  334 

bactericidal  power  of,  88 

cells  in  inflammation,  128 

coagulation  of,  346,  347 

corpuscleo,  poisons  acting  on,  81 
red.    <Sie«  Erythrocytes, 
white.    See  Leukocytes. 

distribution  of,  alteration  in,  336 

dust  bodies  of,  366 

•Making"  of,  360 

plasma,  357 

acidosis  of,  358 
hydremia  of,  357 
hyperinosis  of,  358 
hypinosis  of,  368 
lipemia  of,  358 

platelets,  366 

in  thrombosi?,  347 

qualitative  changru  in,  357 

quantitative  alteration  of,  334 

stasia  of,  339 

sterility  of,  88 

stream,  metastasis  and,  218 

supply,  alterations  of,  337 
Blood-clot,  346 
Blood-forming  organs,  411 
Blood-vascular    tissue,    regeneration    of, 
194 

tumors,  278 
Bloodvessels,  371 


i 


i  i 


I 


I 


1 


714 


I.\l)KX 


BInodvexsclx,  (mdnlholium  of,  infliiiniiiik- 
tiun  liiul,  127 
in  neupltiiiiim,  2'Jl 
Uliic  linn  in  Icitd  iHtisuninK.  32'> 
IkxlioH,  NiiUil,  1!) 

tixroid,  1!) 
Bodily  litate!)  tw  riiiises  of  diseaso.  1 1 1 
Body  cell,  44 
incchuni»iii,  disturbances  of,  auloly- 
aia  tind,  lIMi 
surfaci',  iniiM'rfi'ct  dosiirp  of,  72 
Bonia,  t)7S 

ubnormalities  of,  678 
actinomycosis  of,  ('>85 
angioma  of,  (>!S!) 
at  rophy  of,  685 
caries  of,  081,  084 
cephalhematoma  t ',  07!> 
chondrasarcoma  of,  (»M<t 
cold  abscess  of,  084 
condensation  of,  082 
cvsta  of,  GSK) 
eburnated,  082 
enostoscs  of,  08!) 
exostoses  of,  088 

bursata  uf ,  089 
Kranulonian  of,  085 
f^viminas  of,  084,  085 
hcinantjio-j'nilothelioma  of,  08!t 
hemorrhages  of,  079 
hyperemia  of,  079 
hyperplasia  of,  230,  088 
infarct  of,  080 
inflammation  of,  080,  682 
involucrum  of,  080 
leprosy  of,  085 
marrow,  419 

anemia  of,  419 

chondromas  of,  420 

endotholiomus  of,  420 

fibromas  of,  420 

hyperemia  of,  419 

hyperplasia  of,  419 

inflammations  of,  419 

myelomatosis  of,  420 

myxomas  of,  420 

sarcomas  of,  420 

tumors  of,  2:{0,  420 
metastases  in,  089 
myeloma  of,  089 
myxo-chomlromas  of,  089 
myxomas  of.  089 
myxo-sarconia  of,  089 
necrosw  of,  (JH 1 
ossifying  ecchondroses  of,  089 
oateoiMtrosis  of,  ()82,  085 
Panel's  disease  of,  OSO 
rachitis  of,  087 
regeneration  of,  192  682 
rickets  of,  087 
sarcoma  of,  089 
sclerosis  of,  082 
sequestrum  of,  080 
syphilis  of,  OS  t 


Bones,  transplantation  of,  201 

tuberculosis  of,  682 

tumors  of,  688 
Bradycanlia,  'Mii 
Brain.  485 

abscess  of,  488 

actinomycosis  of,  4!M) 

anemia  of,  486 

aneurysm  in,  488 

angioma  of,  491 

anomalies  of,  485 

atrophy  of,  490 

earcmoma  of,  492 

chori(H<pithclioma  of,  492 

cysticercus  of,  99,  492 

cysts  of,  492 

cehinocoecus  of,  492 

embolism  in,  487 

endothelioma  of,  491 

ependymoma  of,  492 

fioroma  of,  491 

glioma  of,  491 

gliosarcomas  of,  492 

glanders  of,  490 

gumma  of,  489 

hemorrhage  of,  480 

hydrocephalus  of,  486 

hyiM'remia  of,  486 

h>'i)ernephroma  of,  492 

inflammation  of,  488 

leprosy  of,  490 

malformations  of,  485 

myxoma  of,  491 

osteoma  of,  491 

porencephaly  of,  492 

sarcoma  of,  492 

soft(!ning  of,  487 

syphilis  of,  489 

svphiloma  of,  489 

thrombosis  in,  487,  488 

tuberculosis  of,  489 

tumors  of,  491 
Branchial  clefts,  imperfect  closure  of,  7 

cysts,  289 
Breast.    See  Mammary  gland. 

Paget's  disease  of,  672 

"pigeon,"  687 
Bridges,  cell,  19,  20 
Bright 's  disease.    See  Nephritis. 
Bordet-Gengou  phenomenon,  168 

reaction,  167 
Bronchi,  429,  444 

adenoma  of,  446 

carcinoma  of,  446 

chondroma  of,  446 

foreign  botlics  in,  445 

hemorrhages  into,  444 

inflammation  of,  444 

lipoma  of,  446 

lumen  of,  alteration  in,  446 

myxoma  of,  446 

occlusion  of,  446 

ost(  oma  ot,  446 

pa.s.sive  congestion  of,  444 


INDEX 


715 


Bronchi,  porforaliMn  of,  446 

luirconin  of,  44(1 

tumors  of,  44H 
HronohiertiiMiM,  433,  44(i 

cylindrical,  44() 

fusiiform,  44A 

snopulnr,  440 

vuricow',  44»l 
Hninchitiii,  444 

acute,  444 

catarrhal,  444 

chronic,  445 

fibrinouH,  445 

ganiirf  noUH,  445 

purulent,  444 

putrid,  445 
UroncholithH,  446 
lironchopneumonia,  452 

tuberculouM,  401 
Uronzed  diabetes,  579,  703 
Hrown  atrophy  of  liver,  5S.'{,  5S0 

induration  of  lunRH,  44S,  458 
Uubo,  412,  631,  032 
liulhur  paralysis,  499 
KulloiLs  emphysema,  456 
"Bundle  of  His,"  377 
KiirninK  of  skin,  097 
Itursip,  077 

endothelioma  of,  t)7S 

fibroma  of,  07S 

hydroma  of,  678 

inflammation  of,  678 

myxoma  of,   678 

sarcoma  of,  678 

tuberculosis  of,  t)78 

tumors  of,  678 
Hursal  cysts,  292 
Miirsitis,  078 


CwHKXIA,  216 

t  h  yreopriva,  100 

<  'iiissoti  disease,  77,  353 

<  'Mlcarcous  deposits,  313 

in  stomach,  536 

in  tendon  sheaths,  677 

of  thyroid  Kland,  424 

embolus,  3.52 

incrustations,  315 
(':ilciKration,  313 

of  auricle  of  ear,  520 

of  endocardium,  399 

in  infarction,  346 

of  liver,  586 

of  lymph  nodes,  413 

in  myocardium,  391 

of  placenta,  664 

of  veins,  410 
(  ilcium  carbonate  calculi,  310 

"Vrtlate  calculi,  31S 
('  Iculi,  315.    See  also  Concrements. 

biliary,  318  • 


Calculi,  calcium  bi  .rubin,  319 

cholestcrin,  319 

cysti",  318 

Kuanin,  318 

mulberry,  318 

oxalate,  318 

phosphatic,  318 

prostatic,  321,  033 

m  ureters,  023 

uric  acid,  316 

urinary,  310 

xanthin,  318 
Calculous  pyonephrosis,  018 
I  Callus,  formation  of,  193,  703 
I  Calor,  125 
'  Calories,  148 
Cancer.    6'f<  also  Carcinoma. 

"bodies,     266 

cells,  irrcKular  mitosis  in,  222 

"en  cuirasse"  of  mammary  sland, 
070 
of  skin,  707 

"parasites,"  19 
Canities,  708 
Cajjillaries,  409 

denencration  of,  410 

hemanKJo-endotheliomas  of,  410 

hemangiomas  of,  410 

hemorrhages  of,  410 

hyperemia,  338 

inhltration  of,  410 

thrombus,  350 

tumors  of,  410 
Capsular  i;ataract,  515 
Carlxjhydrates,  33 
Carbon  dioxid,  asphyxia  .and,  109 

dy.spnu-a  and,  109 
Carbonic  acid,  muscular  fatigue  and,  114 
Carbuncle  of  skin,  7U0 
Carcinoma,  264 

of  adrenals,  423 

basal-celled,  228 ,  264,  270 

of  bladder,  627 

of  brain,  492 

of  bronchi,  446 

"cancer  bodies"  md,  266 

of  conjunctiva,  ."il") 

degeneration  in.   'i>6,  272 

of  dura  mater,  5< » J 

of  ear,  521 

of  Fallopian  tubes,  654 

of  gall-bladder,  592,  .'593 
-duct,  592,  593 

gland-celled,  272 

of  intestines,  560 

keratinization  in,  270 

of  kidney,  621 

of  larynx,  443 

of  liver,  589 

of  lungs,  465 

of  mammary  gland,  670 

nietluliary,  200,  273,  670 

of  nose,  430 

of  cESophagus,  531 


i 


ir 


710 


rSDEX 


Carcinoma  of  orbit,  517 
of  ovary,  •»")!( 
of  iianrrciw,  697 
of  p<"iis,  ((33 
of  prohtatr,  (536 
RiWKcrB  bodieii  and,  267 
stnr(:oinat<Klc8,  227,  266,  425 
scirrhous,  266,  273,  670 
of  scrofuni,  (>40 
«iiiiplex,  227,  266,  273,  672 
site  of,  tiriKin  of,  2tiT 
of  skin,  7D6 
of  splifn.  4I!1 
gquanidii  -<  I  IIchI,  260,  (572 
of  stomal  h,  M{i 
stroma  of,  2t>"> 
of  testes,  639 
tumor  ((ils  of,  26.'> 
of  urcti-rs,  624 
of  un'ltira,  620 
of  uterus,  651,663 
of  VHKina,  643 
of  vulva,  ()42 
Cardiac  thrombus,  348 

vegetation,  34!t,  351 
Canliovascular  syetem.  333 
Caries  of  bone,  681,  (iH4 
of  joints,  6!)3 
of  teeth,  526 
Carnified  lunKs,  450 
Carotid  fcland,  tumors  of,  285 
Carrel's  exp<-rinieii(s,  202 
Cartilage,  regeneration  of,  102 
Caruncles  of  urethra,  629 
Ciists,  cellular,  312 
colloid,  312 
epithelial,  312 
granular,  312 
hyaline,  312 
waxy,  312 
Catalysis,  28 
Catai-act,  515 
Catarrh,  435 

Catarrhal,  appendicitis,  simple,  557 
bronchits,  444 
cholecystitis,  591 
folitis,  558 
cystitis,  625 
enteritis,  548 
inflammation,  133 
jaundice,  323,  591 
laryngitis,  441 
Cavenitis,  630 
Cavemoma,  278,  705 

of  pia-arachnoid,  506 
of  skin,  705 
Cavernous  lymphangiectasis,  281 
Ceeitls.  548 

Cell,  aonormal  states  ol,  18 
activities  of,  bioplastic.  35 
(X)mp«^n8atory,  37 
excessive,  38 
functional,  38 
katabiotic,  35 


Cell,  activities  of.  relation  of  growth 
35 
•ubnurm.'t!.  37 
vegetative,  38 

alcnliols   of,   33 

biophorii   molecule  of,  24 

blo<Kl,  VZS 

'  .xlv,  IS,  44 

Itriilaes,  >9,  20 

carbohydrates  in  ;i3 

centroHonie  of,  19 

chemistry  of.  24 

chromatin  of,  18 

connectiv^ns,  19 

(■onnective-tissue,  126,  128 

constituents  of,  18 

crystals  of,  1!) 

cytoplasm  of,  19 

damage  of,  by  bacteria,  126 

differentiation,  41 

division,  unitotio,  38 
aster  in,  40 

attraction  sphere  in,  40 
diruct.  38 
karyokinetic,  38 
mantle  fibers  in,  40 
mitotic,  38 

<iynamics  of,  35 

ectoplasm  of,  19 

ectosarc  of,  32 

embolus,  352 

embryonic,  38 

endoplftsm  of,  19 

>-ndoth.  iai,  127,  128,  138 

epithelioid,  i;j8 

faU  of,  33 

germ,  44 

giant,  139 

histology  of,  17 

hyaline,  3(i3 

hyperactivity    of,    within    limit    oi 

reserx-e  force,  38 
lining  of,  18 
lipoids  of,  24 
"mast,"  133,  363 
molecule,   filirlich's  conception   of, 

158 
mononuclear  hyaline,  132 
multiplication.  38 
non-protein  constituents  of,  31 
nucleolus  of,  18 
olein  in,  33 
pabnitin  in,  33 
paraplasm  of,  19 
physiology  of,  21 
plasma,  132,  363 
polymorphonuclear,  128 
iwlyniiclear,  128 
''prexymogens"  of,  23 
proliferants,  201 

proliferation,  inflammation  and,  \\'.> 
proteins  of,  '>A 
regeneration  of,  21 
Kalto  in,  32 


'/^\ 


IN  HEX 


717 


Cell,  Nap,  10 

Higiiificutiie  of,  20 
xiie  of,  2U 
Moaps  of,  33 
Nomstic,  44 
stearin  in,  3.'i 
totipotent,  208 
totipotential,  45 
vacuoles  of,  is 

viiryioK  X»twcn  of  re«i.-.tance  of.  123 
voKt'tative,  44,  216,  217 
wanderinK,  inflainniation  and,  119 
water  in.  31 
( Vllular  casts,  313 
(''■llnlitis.  412 
of  orbit,  517 
of  skin,  4(X) 
(Vntral  pneumonia,  455 
(Vnlrilobulur  pancreatitis,  595 
(  cntmsomc,  19,  .19 
(Viihalheniatoma,  294,  502,  679 
( -ephalothc-racopaKUs  disvninietros,  68 

nicnosymmetros,  69 
("i  robral  ajwplexy,  354 
hemorrhage,  498 
throuibosw,  498 
(Vrobrosides,  27 
Orvical  endometritis,  647 

hydrocele,  281 
(Vrvicitis,  647 
("hali«»si«,  325,  459 
Chancre,  524,  630,  701 
hard,  630 
of  mouth,  524 
of  Hkin,  701 
soft,  *>3l 

<  liiincrojii.  631 

<  'jiarcot-Uyden  crysUls,  445 
(  hun-ot'n  joint,"  694 

Cliiiliris,  523 

niiiloRnathopalatosrhisis,  5_'2 
wieiloKnathoprosioix.-'chisiB,  522 

<  lieiloffnathoschif-is.   ,22 
(lieiloschisis,  522 
Clieioid,  231 

<  liumical  causes  of  disease,  75,  78 

of  inflammation,  122 
J  Kiniotaxia,  inflammation  and.  119 

<  liemosis,  ;i66 
'  Xi'.vne-Stokes'  respiration,  431 

*  hickenfntclot,  346 
'  liiKoe  in  skin,  703 

<  lulls,  fever  and,  149 
'  liloasma,  703 

<  l.loroform  poisoning,  necrosis  of  iiver' 
III,  oao 

<  liioroma,  238 
'  Morosis,  "(SI 

•  ;i"ku<l  disk,  507,  510,  516 
'  'f.laiiKitis,  .591 
'liolrovstitis,  .591 

<  '"iiiuhiasis,  318 
: '"iestpatoma,  284.  312,  506,  519 

'     ilestenns,  27,  319 


Cholin,  106,  110 
Chondtin,  34 
Chondrodystrophia  f.t  lalin,  678 

3»0  '^''"'■"•"■''''°"  "f  '"yocanlium, 
■pleen,  309 
Chondroma,  234 

of  bone  marrow,  420 
of  bronchi,  410 
of  dura  mater,  'AYA 
,         of  lungs,  465 
!         of  mammary  gland,  672 

of  mouth,  .")26 
j         ofplei,,:    .J7() 
I         of  vui .        12 
^  Chondro-osteo-snn-oma,  689 
Chondrosarcoma,  256 
i         of  bones,  «i89 

Chonl«.  tendinea.,  alx'rrations  of,  393 
Chordec,  629 
Chonloma,  249 
Choreiform  movements,  484 
Chorio^pithelioma,  212,  663.  664 
of  brain,  492 
of  lungs,  466 
of  placenta,  664 
of  testes,  6.19 
of  vagina,  643 
Choroid,  hemorrhages  of,  510 
hyperemia  of,  510 
inflammation  of,  513 

sarconi..  ,,  melanotic,  515 
I         tumors  of,  51,5 
j  Choroiditis,  513 
I  Choroidoretinitis,  51  o 
j  Chromaffin  cell,  niulti|ilir  ,  ;  >„  ;>  ,    22 

system,  disea-ses  r.     i.'»  ;<     m.' 
I  Chromatin,  18 
Chroniatophoroma,  28.'!        ■. 
I  Chromiilia,  22 
j  Chromophilic  bojlies,  47.i 
Chromosomes,  39,  45 
Chyliforiuascites,  370 
j  Chylous  ascites,  370 

hydrothorax,  370,  467 
Chyluria,  370 
CicatrJMtion  in  gangrene,  330 

in  infarction,  345 
Ciliary  body,  inflammation  of,  .5:U 
Ciliatc  infusoria.  97 
Circulation,  collateral,  development  of, 

coronary,  376 

organs  of,  fxiisons  acting  on,  82 
Cirrhosis,  141 
of  liveij  575 

bihary,  579 

Hanoi's,  579,  ."JSO 

hypertrophic,  579 

La?nnec's,  575 

uHinolobuiar.  r>80 

iiiultilobiil(,r   ")76 

obslructivi    .)79 

ponal,  575 


r 


718 


INDEX 


m 


il'  i 


Cirrhosis  of  liver,  svphilitir,  .Wl 
Cirsoid  iincurysni,  27S,  407 
CliMlothrix  of  luiips,  405 
Clasniatocvtps,  133 
Cleft  pahilV,  74,  437,  522 
C'ilons,  040 

absence  of,  040 
hyperplasia  of,  MO 
Cloaea,  persistent,  74 
Clonus,  4S2 
Clot,  1)I(«m1-,  340 

chickenfat,  340 
Cloudy  degeneration,  123 
swellinfj,  123,  3(»1 
of  kidney,  01!) 
of  liver,  5.S4 
of  muscles,  075 
of  myocardiuni,  3XH 
CoaRulation  necrosis,  32S,  344 
Coajtuline,  347 
Coarctation  of  aorta,  387 
Cocci,  84 

CJoecidia  of  sporozoa,  07 
Coccidiosis,  250,  5!K) 
Cold  abscess  of  bone,  084 
Colic,  urete-al,  o23 
Colitis,  558 

amo'bic,  558 

baeillary,  epidemic,  558,  550 
catarrhal,  558 
follicular,  558 
membranous,  558 
mucous,  558 
ulcerative,  558 
tuberculous,  500 
Collapse,  178 

of  air  sacs,  431 
Collateral  anemia,  330 

circulation,  development  of,  343 
hyperemia,  337 
Colli(i'uative  necrosis,  328 
Colloid  carcinoma  of  stomach,  540 
ciist,312 

defeneration,  3(K>,  307 
in  carcinoma,  272 
deiiosit,  30<»,  307 
i)ropert  ies  of,  32 
Coloboma,  509 
Color  blindness,  47 
Colostrum,  GtiO 
Coma,  4H0 
Combined  proteins,  25 

sclerosis,  subacute,  501 
Conie<lones,  707 
Compensatory  cell  activity,  37 

hypertrophy,  188,  (i30 
Complement,  KM 
Complemcntoid,  105 
Compression,  70,  450 
Conception,  products  of,  004 
Concrements,  315 
Concretions  in  proslale,  033 
Concussion,  75 
Condvloma,  258,  020 


1  Condensation  of  bones,  682 
CondensinK  osteitis,  082 
Congenital  i  ystic  kidney,  289 
cysts  of  pancreas,  508 
disease,  55 
IM)renc<'phaly,  408 
sacral  teratoma,  208,  209 
spastic  paraplegia,  408 
Congi.-jtion,  passive,  338 
of  liver,  570 
of  peritoneum,  502 
of  spinal  cord,  405 
of  vagina,  042 
in  pneumonia,  452 
of  spleen,  415 
of  thyroid  gland,  424 
Congestive  u-nlcma  of  lungs,  369,  447 
Conjunctiva,  509,  510 
carcinoinii  of,  515 
fibroma  ot,  515 
hemorrhages  of,  509 
hyperemia  of,  500 
infective  granuloma  of,  511 
inflammation  of,  510 
leprosy  of,  511 
lipoma  of,  515 
(edema  of,  500 
osteoma  of,  515 
papilloma  of,  515 
sarcoma  of,  515 
syphilis  of,  511 
tuberculosis  of,  511 
tumors  of,  515 
Conjunctivitis,  510 
Parinaud's.  511 
Connect  ive-tiwue  cells,  127,  128 

(lew-formed,  vascularization  of,  136 
pelvic,  tiOl 
regeneration  of,  101 
Constipation,  111,  542 

Bacillus  coli  and.  111 
"Consumption,  galloping,"  462,  40.'i 
"Contagious,"  distinction  of,  from  "in- 
fectious," 00 
Continued  fever,  149 
1  Contracture,  484 
1  Contusion,  70 
I  Convulsions,  480 

focal,  482 
I  Jacksonian,  482 

Cor,  biatriatum  triloculare,  .386 
I  biventriculare  Irilocidare,  386 

I  Cord,  spinal,  403 
I  Corn,  703 

[  Cornea,  fibroma  of,  515 
her|)es  of,  512 
infective  granuloma  of,  512 
inflammation  of,  511 
myx(mia  of,  515 
papilloma  of,  515 
sarcoma  of,  515 
syphilis  of,  512 
tunerculosis  of,  512 
tumors  of,  515 


i 


INDEX 


719 


Cornea,  tilccr  of,  511,  512 
I'oronary  cirrtilaUon,  376 
CoriKjra  aiiivlacna,  321 

of  brain,  4<JC 

in  prostatp,  633 

in  spinal  ror<l,  4'.M) 
oryzoidea  in  joints,  6!t4 
Corporeal  endometritis,  647 
Corpusclos,  re«l.    .SVe  Erythrocytes. 

white.    See  Leukocytes. 
Coryza,  435 
CdiiKhinfc,  430 
Cuwper's  ghtnds,  (i36 

cysts  of,  630 

inflaniniation  of,  636 
Cnmial  meninges,  5()1 
Cninio-tabes,  687 
Crcatinin  in  urine,  <M)2 
Creeping  pneumonia,  453 
Cretinism,  KM),  678 
Crisis  in  infection,  14!) 
Cryoscopy  in  nephritis,  606 
CryptoRenic  abscess  of  brain,  48S 

infecti<m,  S9 
Cryptorchidism,  (W7 
(  ry.stals  of  cell,  1!) 
Ciiiindalive  inheritance,  50 
Cii|)pe<l  optic  disk,  516 
Ciirschmann's  spirals,  445 
CiilMiu'ous  concrements,  315 
(  iil:iiic()us  horns,  2.59,  312,  703,  705 
Cv,iiM.sis,  .339,  69ti 
Cvaimtic  induration  of  kidney,  <>09 

of  liver,  572 

of  luns;K,  448 

of  spleen,  4U> 
Culicjil  all)uminuria,  603 
(•■-.  litis,  512 

<  Ml(pps,  70,  71 

< '\liiiilrical  bronchiectasis,  446 
(■\lin.lr.)tna,  283,  311,  528 
111'  siihvary  Khirids,  .528 
C\liriclr()inatous     tivahnc     degeneration, 

:;ii 

<  v  li:iuc-||(',  .VJS 

<\  1  fi)rination  in  infarction,  345 

<  \-i.iil(!ioma.  •>'•}.,  291 

of  I. vary,  t).',(),  6.")9 

"f  pancreas,  .597 

|i  ipiUifcruin  of  mammary  gland,  670 

I'f  pcritoneiim,  .567 

<  •   ■  II-  carcinor-in  of  ovary,  6.59 

liV(jroma,  281 

kidney,  congenital,  291 

'.MiipiiaiigiectaMls,  281 

mastitis,  chronic,  670 

iinitoma  of  ovary,  (MM) 
C'     iiiTcus  of  brain,  99,  492 

"i  nuisclcs,  ()75 

'I  pcricardiun;,  385 

"I  ureters,  624 
*■      i'l,  lOS 

iliuli,  318 
*^        iiuria,  108 


Cystitis,  625 

catarrhal,  625 

phlegmonous,  625 
;  Cystocel",  642 
Cystoma  of  ovary,  6.56,  658 
Cysts,  287 

of  adrenals,  423 

of  antenatal  origin,  289 

of  bones,  690 

of  brain,  487,  492 

branchial,  289 

of  breast,  670 

bursal,  292 

of  canal  of  Nuck,  291 

composite,  293 

congenital,  289 

of  Cow[)er'8  glands,  636 

<lermoid,  of  mediastinum,  471 

distinction  of,  from  tumors,  287 

dentigerous,  293 

endothelial,  291 

efwndymal,  292 

of  Gartner's  duct,  289 

of  glands  of  Bartholin,  642 

hemorrhagic,  237,  293 

hydatid,  295 

of  intestines.  .544 

of  kidney,  622 

of  larynx,  443 

of  liver,  .5iK) 

lymph,  292 

of  manunary  gland,  (i67,  670 

nuicous,  290 

necrotic,  287,  294 

of  neopla.stic  origin,  291 

of  ovary,  6.56 

of  pancreas,  .598 

panisitic,  288,  295 

of  i)enis,  (i;{3 

of  peritoneum,  .567,  .5()8 

of  placenta,  664 

of  |)ost natal  origin,  2t)0 

of  primordial  genito-urinary  -.iucts, 
289 

of   prostate,   6;{3 

retention,  287,  288 

salivary,  2!H) 

sebaceous,  of  ear,  ,521 

secretory,  288 

se(iu«"stration,  293 

of  skin,  707 

s(|uam(>us  epithelial,  292 

of  t  tenia  echinc-occus,  295 

of  teeth,  .528 

of  testes,  639 

of  thyroid  gland,  291,  424 

thyrolingual,  289 

of  Trichina  .spiralis,  295 

of  umbilical  cord,  t)65 

urachal,  289,  625 

of  ureters,  t)24 

of  uterine  ligaments,  6«M,  662 

of  uterus,  6.52 
i         vitello-intestinal,  289 


ij 


f^ 


720 


INDEX 


Cysts  of  vulva,  642 

of  \\  olffian  body,  289 
Cvtolysins,  163 
Cytolysia,  -iOO 

ninchanism  of,  164 
Cytoplasm,  18,  19 
Cytotoxins,  163 


DAruYOPa,  290 
Deaf-mutism,  o20 
Death,  ;{3() 

somatic,  331 
Decifluoma     malignum     of     puerperal 

uterus,  663 
Defect  of  special  repons,  70 
Defences,  normal,  of  organism,  86 
Defervescence  in  infection,  144 
Degenerates,  .W 
Degenerations.  300 

of  adrenals,  422 

albuminous.    See  Cloudy  swelling. 

amyloid,  306,  307,  308 

of  iirteries,  401 

of  axone,  478 

of  capillaries,  460 

in  rari'inoma,  272 

chondrcid,  309 

cloudy    123 

colloid.  272,  .3I)«,  307 

cvstic.  "f  ovarv,  t),")6 

fiastoid,  309 

familial,  50 

"fatty,"  123,303 

granular,  123 

liematohvaloid,  31 1 

hyaline,  123,  306,  309 

liydropio,  306 

of  kidney,  (520 

lipoid,  30.T 

of  liver,  584 

of  lymph  nodes,  413 

rimcoid,  .30«),  307 

of  muscle,  676 

of  niyocariliuni.  389.  390 

in  neoplasms,  222 

,)f  pancreas,  597 

of  placenta,  664 

of    irostate.  634 

of  retina.  514 

of  spinal  ci.i-d,  496,  497 

'if  splwin,  !iS 

of  thyroid  gl.'ind,  424 

of  tumors,  acute  red.  650 

III  umbdi'.-al  cord,  365 

vaciioliir,  306 

Wallcrian,  198 

waxy,  328,  676 

Zenker's,  328,  676 
Delhi  boil,  "."o 
Delirium,  480 

cordis,  380 


Delirium  tremens,  480 
Dementia  paralytica,  4.''9,  490 
Dendrites,  pathological  changes  in,  4 

477 
Dental  hyperostoses,  527 
Dentigerous  cysts,  293 
of  bones,  690 
I  Deposits,  calcareous,  313 
I  Dermatitis,  blafitoniycetic,  92 
j         of  penis,  ti30 
'  Derm  atomy  cosis,  702 
i  Dermatomyositis,  704 
Dermoid  cysts  of  mediastinum,  471 
of  uterine  ligaments,  662 
inclusion  of  pia-arachnuid,  606 
ovarian,  209 
;         of  skin,  707 
Determinants,  42 
Diabetes,  bronzed,  579 

predisposition  toward,  115 
D  abetic  coma,  109 
!  Diacetic  ac!  ',  109 
Diapedesis,  124 
Di.aphragmatic  hernia,  569 
Diurrhoca,  543 

I  Diastatic  enzymes  of  bacteria,  84 
i  Diastol.'  of  heart,  375 
Diathesis,  56,  ")7 
1  Dichorial  twins,  62 
i  Dichotomy,  polar,  66 
I  Difluse  parenchymatous  goitre,  424 
i  Digestive  system,  522 
I  fever  and,  151 

I  po'sons  acting  on,  82 

:  Dilatation  uncurysm,  407 
of  intestines,  545 
of  myocardium,  392 
!  (.f  uterus,  t)46 

I         of  veins,  410 

■  o\  ventricles  o<  heart,  375 
DiiiK'thylamin,  110 
Diphtheria,  138 

of  external  ear,  518 

of  a-sophagus,  531 
Diphtheritic  membrane,  438 
Diplogemsis,  causes  of,  64 
iJirect  cell  division,  38 

inguinal  hernia,  569 
Disease,  acquired,  55 

cau.ses  of,  55 
!  chemical,  75 

■  intra-uterine,  58 
mechanical,  75 
pprasitic,  75 

j  partvirient,  .58,  61 

j  physical,  75 

I  predisposing,  55 

;  functional,  58 

j  of  nerves,  47*^ 

inherited,  .55,  M 
postnatal  acquirement  of,  74 

Disintegrative  intoxications,  SO,  w.< 

Disk,  chok<Hl,  .507 

Dislocation,  congenital,  of  hip,  <> «', 


INDEX 


I  )isl(K,'atioii  of  Icn.-i,  .j<)it 
Dissecting  aiiciirysiii,  4(17 
Disyiiiiiii'trii'ul  jaiiiccps,  (is 
Distent  ion,  a  caiiM-  of  disease,  7(1 
Dislonittni  in  liver,  ■'>!)() 

WestiTinanii  of  liiiiKs,  4(m 
Disuse  as  cause  of  disease,  11.") 
Diversion  of  coinpleinent,  ititi 
Diverticula  of  Fallopian  tliln's,  (io;! 

of  intestines,  o4."; 

Meckel's,  .-)44 

of  (I'sopliatjus,  MO 
Ducrticniitis,  ."15 
Diilar,  12.') 

Diiiiiinant  properties,  47 
Dcirsal  (jroove.  imperfect  closure  of,  71 
DdiiMe  cleft  palate,  74 

monsters,  (>4 

penis,  (>;}() 
Diiiiriiie,  !•.") 
I  'r y  uanurene,  ,'<3() 
Dry"  pleurisy,  4(>S 

tenosynovitis,  (i7(> 
I  >iiilus  arteriosus,  patent,  ;{S('> 

Uolalli,  pa!-ciit,  ."{.Sti 
Duiiicluni       fever,       Leisliinan-Donovan 

liiiilies  and,  it,") 
I  liiiiijenilis,  .">4S 


Dii 
ll>i|ili. 


Ii'iuiin,  .')41 
icalioii,  fiisional.  (>S 
of  rnyocardiuin,  .'iS.l 
111  (esophaKUs,  .")2(( 
of  organs,  70 
of  pancreas.  .")!)4 
I  if  v.mina,  ()42 
iiini  Miater,   lOl 

carci  loiTia  of.  .")04 
clioridrotna  of,  .")(i.) 
encjotlielioina  of,  .")0;i 
til>roina  of,  .")0;{ 
lieniorrliiuics  of,  .'lOl, 
inflaniniaticn  ot,  ."i02 
osleoina  of,  .">IK! 
p>:tMjirioina  (il.  .')(KS 
sarconia  of.  .")0I 
s\  philis  of,  .")0;i 
I'lnmihosis  of,  .")0I 
tulierculosis  of,  7i{y.\ 
luniors    if,  .")0;t 
>ii-i  liiidies  of  hliiod,  .'i(i(l 
'  '  nii^rii.  70.  (i7s 
•    -Tll..ry,  .Mo,  ."i,")'.! 

isiiiMiion  of,  from  di.irrli 

i.i  of  utei'us,  (>l  I 
'■■la,   IO!l,  4:i(l 
'in.c  ol'  Irsiis,  (i;j7 
I  illrril^,  (11 1 


iiiiiiiiiialilies  of, 
lll.le  (if,  .■|I7 


.•|(I2 


\'<    ■\'Va 


,")4;i 


Ear,  auricl<!  of,  calcification  of,  ")20 
liemorrliaKC  of,  .)17 
\i}  pereniia  of,  .")I7 
inllaniination  of,  'AS 
<lrum  inemliranes  of,  .'il7 
ah.sence  of,  .")17 
atrophy  of,  ,")20 
liemorrliaKc  of,  .">1S 
jiypereniiti  of,  517 
inHaiinnatioii  of,  51.S 
Eustacliiaii  lube  of,  517 
e.vternal,  ah.sence  of,  517 
ah.sence  of,  517 
angioma  of   .")21 
carcinoma  of,  ,")21 
diphtheria  of,  51,S 
duplication  of,  517 
eczeniii  of,  51N 
exosto.ses  of,  520 
inflanunation  of,  51.S 
fihroina  of.  ."21 
furuncle  of.  51,s 
Kranulomas  of,  infective,  51» 
lipoma  of,  .521 
myco.sis  of,  51!S 
osteoma  of.  .">21 
periostitis  of,  5IX 
sarcoma  of,  521 
.sehaceous  cyst  of,  521 
stenosis  of,  517 
syohilis  of,  5I.S 
lllhen'ulosis  of.  51S 
internal,  alisence  of,  517 
hetiiorrhatje  of,  51.S 
liynereiiiia  of.  51X 
inflanimalion  of.  .")2() 
t   iddle.  adenoma  of.  .521 
angioma  of,  521 
carcinoma  of.  521 
fibroma  of,  521 
liemorrhaije  of.  51S 
hyperemia  of.  51.S 
inllainmation  of.  51S 
saricirii.-i  of,  .")2I 
lubinulosis  of,  ,j20 
llburnat.'d  bone,  (W2 
licchymoses,  W'^'y 
I'^'hinococciis  of  br.iin,  11(2 
c.vsts  of  pancreas.  5'.<.s 

of  uterus,  (5411 
hvda'    I,  2<14 
of  lun^s,  4()5 
of  muscles.  1175 
of  p"ric!irdium.  W5 
of  ureters.  (124 
Iv'lampsia,  1  10 
Ij'lopia  of  bladdir,  (i2t 
cordis.  72 

of  myocardium.  :fS5 
vesi  'a-.  7.'i 
lOiopic  gestation.  (i(i(i 
Kctoplasm    10 
I'lctosarc,  ;i2 
Kctoto.xie  huiMeria.  !S5 


I 


i 


I 


v=l 


722 


IXDKX 


5  IS 


17 


r:i 


Krtoldxilis,  l.'iCi 
Kczcin.'i,  WIS 

i>f  auditory  iiicaluw, 
niuiliiliiii.-i.  til)!) 
papulosiiiii,  titIS 
pustulosiiiii,  tit)*.) 

vcsiciili)siiiii,  ti!)!) 
lOITcri'iit  iMTvim.s  system 
KITiisioii,  iiloural,  V-iA 
K^lt  alhiitnin,  2'> 
Klirlicli's  orders  of  reeeplors,  17:5 

side-('liaiii  llieory,  172 

theory  of  iinimitiitv,  1;")7   ItiO.  172 
i:iastiii,  :{"4 
Klastoid  chaiijres  in  ovary,  ti")ti 

detjeneralio.',  ;iO<),  401 
Mlectricitv  as  eailse  of  disease,  7S 
Kleidin,  ;n2 
Klephantiasis.  til,  2S1,  411,  71)4 

iieiiroiiiatosa,  .")()!) 

of  penis,  ti;{2 

of  scroluin,  ti40 

of  vulvii,  ti4I 
lOlevalion  of  uterus,  t)4.") 
I'jnholie  pneumonia,  4.")7 
Kmliolism,  ;«•),  :i.'.l 

in  lirain,  4S7 

of  kidiie.\,  tiO!) 

of  liver,  .'u'-i 

in  luntjs,  44!) 

of  iymjih  ikmIcs,  412 

of  peritoneum.  ")ti;i 

of  spleen.  41)) 

in  retina,  .'ill) 

stomaeli  anil,  'M 
I'jnholiis,  air.  :{.")2 

atheromatous.  ;{.")2 

haeterial.  ;{.'>:{ 

ealrareous,  U.52 

eell.  :!.VJ 

fat.  :i.VJ 

liireidn  hodv,  •{■">•{ 

uas. :{.-.;( 

menaearyoeyte,  .{.VJ 

parasitic.  ',iXi 

pigment.  :{5;i 

"richnK,'   -i")! 
Mmhryomas.  sporatlic,  20!) 
Mmtiryonie  eell,  US 

malitjnaliev   of   neoplasms   .irid 
2Iti 

tumors.  22ti 
Kin|.hys.Miia.  2!)S,  4,T_',  4.-)l),  »l>!) 
lOmpvema,  4t>!) 
Kiieephaliti-.   ISS,  4S!) 
Kneephalomal.'ieia,  4S7 
Knehonilioma.  2.'i4 

of  larynx,  44:{ 
Kneysted  hydroec  Ir,  2s!) 
i'jidarleritis  ot)liter;ins,  10.") 
Kndemie  lnfe<'tion,  14;( 
Endoearditis,  :{!).< 

aortic,  S!)4 

gonorrlueal  urethritis  and,  112.) 


EndocardiliH,  inaliKnaiit,  ;{!H) 
mitral  iiieompetenee  in,  :!!)" 
NieiiosiH  ill,  3!)7 
simple,  .'{!).') 
ulcerative,  :i'M\ 
venetative,  ;{!)4,  MH> 
verrueose,  :{i)4,  :i!)"i 
Kndocardiuni,  ;J!)3 

abiiornialitips  of,  .'{1)3 
atheroma  of,  'A'M) 
cidcitieation  of,  :W!) 
clerfC'iierative  changes  in,  ;5i)9 
hematomas  of,  ;i!);{ 
heiiiofclohiii  iinbiliitiun  in,  393 
hemorrhaKes  into.  3!)3 
inHaniniation  of,  3!).'{ 
net  rosis  of,  3!)1) 
Kniloijenous  intoxications,  7!),  100 

pigment  ut  ion,  321 
Kndomelritis,  ti47 
cervical,  647 
(•oriM)real,  ti47 
neiirral,  t)47 
glandular,  ()4S 
heinorrhadic.  ti47 
interstitial,  tilS 
i'jidoplasin,  1!) 
Kn(losmoHi.s,  32 
Kiidosteal  osteoma,  23.') 
Kndothelial  cell.s,  127,  13S 
cy.sts,  21)1 
neoplasms.  22ti 
spleiioniecaly,  241 
li.ssuis.  22»'> 
Kndr)tlielionia,  227,  274,  277 
of  hone  marrow,  420 
of  brain.  4!)1 
of  bursa'.  I)7S 
of  iliira  mater,  .")()3 
of  luntjs,  4().") 
of  lymph  nodes.  414 
of  mammary  ^lalid,  Ii72 
'if  nose,  431) 
of  ovary,  ().">!),  litM) 
of  penis,  ti33 
of  peritoneum,  .507 
of  pia-aracimoid,  "lOI) 
of  pleura,  47t) 
of  salivary  (tlaml,  ')2S 
of  uterus,  t).")2 
luidolheliuiii.  22.") 

of  l)loodvessels  in  inllaMinKilioii, 
regeneration  of,  l!)ti 
iCndotoxie  bacteria,  M 
Kndotoxins.  l")l) 

F^nnorReineiit  in  pneuir.onia.   I.j2 
iMiostosis,  23ti,  tiSi) 
l')ntamii'ba  coli,  !I3 

hystolytica,  !)3.  1)4 
luileritis,  .■)4S 

catarrhal.  ■')4S 
follicular,  .'vl!) 
membranous,  .")4!) 
phlejjmonous,  540 


B^ 


INDEX 


723 


Ktilororplc,  (142 

KntcrokinuBC,  iictivutinn  of  trypMnoKon 

')>',  174 
lOniircsis,  iiorturniil,  ti()5 
Knz(><>li(!  inffctioti,  143 
l'ti?;'inc  action,  27 

Kniwth  und,  30 
liydrolywis  and,  32 
k:.!.'i'i.si.s  and,  2.S 
rovi  rsibility  of,  ;jO 

anliiiiastatic,  1,56 

antippplio,  1.56 

of  l)a('toria,  S4 

di.stitiction  of,  from  formonts,  28 

pxtracc'lluiar,  2S 

iniMiunity  afcainHt,  15,5 

inlraopllular,  28 

of  Iciikooytj'.s,  1(M5 

rcscinblanpc  of,  to  toxin.s.  So 
l^iisiiiophiles,  in  influrnniation,  12S,   I2it, 

:iti2 
Kiisiiiophilia,  !M»,  3<)4 
Klii'iidyfiial  cysts,  2!»2,  492 
l!|ii'iiilvinonia,  247,  4!)2 
ICpibhisi,  223 

I'^liild.'i-itic  nooiiliisms,  22.5,  226 
l.|iiil"'!nic  bacillary  colitis,  5.5N,  ,5,50 

iiifi'ction,  143 

parrititis,  52S 
lliiilidvniis,  637 
1  l>it.'ii:illn!s,  6.5,  2(H),  437,  .525 
Ipini'iilirin,  102 

liiiphysis  ccrobii.    ^cc  Pineal  uland 
I  pipliysitis,  6S1 
I  pi-|).'idias,  73,  628 
Ijii-i.'ixis,  434 
l.piil.rlial  casts,  312 

1  ysts,  squamous,  2!t2  i 

rm'tapliisia,  204 

pearls.  26<t 
I  p;'li>-li(.i(l  cells,  I.3S 

1  piil,(|i(,iri:i.    26!t.    .S'cc  also  Carcinoma, 
s<|uaiiious-ccllcd. 

"I  iiioulh.  .525 

iif  ii'.-opliamis,  .531 

"f  Nkiti.  7(Kj 

of  stoniiiclp.  .53(1  j 

of  uterus,  651 
I     I'liiliurii,  ri'Kcncration  of.  I'.)4 
'     /iiiitir  iiifcitidii    143 
I     ill-,  J30,  .52") 

lil.rous,  68!) 
'     "iMiiN,  licmorrhattic,  of  stomach,  .5.il 
*       ipHas,  7(10 
i      ili.'riia,  6117 
I     .  ilirocylcs,  35H 

liiiiioKlobiii  contctil  of,  3.5i» 

licinolysis  of,  ;i.5<.t 
■''ir>plin(j"  of,  3.5it 
I         iTil.jci.  in  typhoid  fever,  .5.50 

I'lriitylus  Ki|{.is  in  lu'cters,  621 
Hiheinala.  pn>disj)(isition  toward,  115 
I       •lions.    P-orpiiou    of,    intoxications 
to,  105 


Kxcnccplialy,  72,  485 

Kxercisc,  hypcrtropliy  due  to,  IS7 

E.xof;cnous  intoxications,  71> 

pigmentation,  324 
Exophthalmic  ({oit re,  101,  424 
Kxo.^mosis,  32 
Exostosis,  2.36,  688 

of  bones,  088 

bursiita  of  Ikjucs,  tiSO 

of  pxtprnal  car,  .520 
Extrophy  of  bladder,  621 
"Exuberant  "  granulations,  1.38 
Exudate,  134 
Exudative  choroiditis,  513 

plcuri.sy,  467 
Eye,  .5(K» 

anomulieH  of,  .5(K» 

inflammation  of,  .510 
Eyestrain,  50i) 


FAn.\L  clefts,  imperfect  closure  of,  73 
F'acultative  anaerobes,  84 
Fallopian  tubes,  6.52 

abnormalities  of,  0.53 
absence  of,  6.53 
carcinoma  of,  6.54 
diverticula  of,  6.53 
double  orifici-  of,  6.53 
fibroma  of,  654 
Ronorrhn'al  infection  of,  t)54 
hemorrhage  of,  6.53 
hyperemia  of,  ().53 
inflammation  of,  6.53 
lipoma  of,  654 
myoma  of,  6.54 
papilloma  of,  ().54 
sypliilis  of  6.54 
tumiifs  of,  654 

tubereul<>us  infection  of,  654 
False  hermaphroditism,  74 

neuroirias,  .50it 
Familial  charai'ters,  47 
<lepeneration,  .50 
inheritance,  47 
immunity,  1 15 
Family  type  of  lateral  sclerosis,  4!t!> 
Fastiniuin  in  infection,  144 
Fat  in  cell,  .33,  302 
embolism,  352 
formation  of,  in  fat  cells,  23 
necrosis,  32.S 

of  panc,-eas.  .5(15,  .507 
serous  jitropliy  of,  2(18 
-forniinn  ferment,  34 
-splitting  ferment,  .33 
FatiKue,  111 

muscol.'ir,  113,  11  1  , 

of  nerve  I'cll,  1 14 
Fatty  deneneralion,  123,  303 
of  kidney,  t)20 
of  liver.  ,584 


I 


■I 


1 


724  IXDEX 


[V 


Fully  ilruciioration  of  iiiusclfs,  (17.") 
of  inyocanliuin,  :isy 
of  paiHTCits,  .V.»7 
of  prostate,  (WW 
iiitiltrati<iii.  ;«)2 

of  I'lMI',  .')S4 

of  iiiy<ic!irclhiiii,  .'{SH 
of  pancreas,  ."i'.>7 
tissue,  reKeiierat ion  of,  Il'l 
Fauces  of  tonsils,  4;{(i 
Fa>us,  702,  7()s 
Febrile  all)inniiniria,  1.'>I 
F'einoral  hernia,  ")•>!• 
Feiiestrati  >ii  i>f  setiiiluiiar  valves,  ;{!>;{ 
Ferments,  distiiiciioii  of,  ir  )iu  eiizyna-!*. 
•JS 
fat-fortuinu,  'M 
fat-splilliiiK,  S.i 
lipolytic  :i4 
Fertilization.  It 
Fervescence  ill  infection,  144 
Fever,  14',t 

asthenic,  loO 
chills  ami,  140 
continued,  \W 

disturbances,  associateil  with,  14M 
in  blood  and,  l-')(> 
in  circulatory  system  and,_  lot) 
in  dineslive  system  ami,  l.")l 
in  nervous  system  and,  14".),  l.'O 
in  resi)iration  and,  l.")l 
in  urinary  system  and,  ..'jI 
intermittent,  14',t 
relapsing,  '.IS 
re<Mirrent,  14!t 
remittent.  1411 
rigor  and,  l.'id 
sthenic.  1'><I 
typhoid,  .")4!l  .")."):( 
Fibrillary  twilchinu  of  muscles.  4S4 
Fibrillation  of  heart.  :{M_I 

of  vilriHUis  hutrior.  ."iHi 
Fibrinogen,  2.") 
Fibrinous  bronchitis,  44.') 
intlamm.ation.  i:M 
pleurisy.  4(iS 
vegetal  ions,  lo.") 
Fibro-adenoma  of  n)an:tiiar.v  tiand.  litiit 
Fibroblasts.  12.-),  i:fl.  ITJ 
Fibro-enchondronia.  2:)4 
••Fibroiil  phthisis."  4(12,  4t);{ 

uterine,  241.  (i.Vt 
Fibroma,  22i> 

of  boni'  marrow,  420 
of  brain,  4111 


of  bladder,  (".27 
of  bursa',  t>7.S 
of  conjunctiva, 
of  cornea,  ."il.-) 
of  ear.  .")21 
of  l'"allopiali  lubi 
of  intestines,  .■|l')0 
of  ki<lm-y.  (121 
of  larynx,  44;{ 


.-.l.-) 


,    (Ml 


Fibroma  of  liver,  .W,) 
of  lunn^,  4(1.-) 
of  mammary  kIuikI,  (172 
of  mouth,  .VJ.-),  .-)2l) 
of  inu.scles.  t)7t> 
of  inyoi'ardiuin,  '.HKi 
of  nose,  4;{(> 
of  ovary,  ().')!> 
of  penis,  (ilW 
of  peritoneum,  .j()7 
of  pia-antchnoid,  ^I'M 
of  placenta,  ()(>4 
of  pU'ura,  470 
of  .skin,  705 
of  stomach,  i>'-i\i 
of  urethra,  (12!) 
of  uterine  lit;aiiieiils,  062 
of  vulva,  (141 
Fibronmtoid  growths,  'j;«) 
Fibromatosis,  247 

of  mammary  gland,  f)6S 
of  optic  nerve,  .")I7 
of  perii)heral  nerves,  .tOO 
Fibroinyoma  of  placeiitu,  004 

of  uterus,  ().")() 
Fibrosan'oma,  2.')0 
Fibro.sis,  12,-),  141 

in  arteriosclerosis,  142 
(lup  to  strain,  14H 
of  heart  valves,  H!)H 
inflammatory,  142 
of  lung,  interstitial,  405 
of  myocardium,  liS7,  391 
ncopla.stic,  143 
non-inllaiinnatory,  143 
l)ost-fibrinoiis,  143 
liroliferative,  142 
reph"'*'""''!*'  142 
of  veins,  410 
Filaria  nocturna,  ".)'.) 

sanguinis  in  ureters,  024 
Filariasis,  411 
Fillnible  viru.ses,  i)2 
Fission  of  o.s  uteri,  044 
Fissure,  abitominal,  72 
sternal,  72 
vesico-vagiiial,  73 
I'issured  larynx,  440 
I'istula  in  aiio,  555 
of  larynx,  440 
re<'tovaginal,  043 
uterorectal,  044 
uterovesical,  044 
vesico-umbilical,  025 
vesico-vaginal,  043 
Fixation  of  complement,  1(17 
Fixed  tissues  in  inflaminution,  l.ii 
Flugellala,  04 
Flat  worms,  OS 
Fleshv  mole,  212,  004 
Flexion  of  tlterus,  045 
Focal  change  in  nervou.s  system.  i»- 

necrosis,  .32.S 
Fcvtal  adenoma  of  thyroid  gland.  ' 


MJ: 


I  .•  --rV'  r"j«fe;':-  -..  -m 


■ET9W? 


^SiVrniU 


■    'Ain :W 


mmmmsam 


ISDEX 


Kd'tal  inclusions,  "JltS 

lobulution  of  kidney,  r><)S 
I'ifliis,  tMlo 

acanliiicus  iinrops,  (>:{ 

.•ii'i'i)h!ilu.s,  (i2 

acorniilK,  Ki 

aiiiorphiis,  (>2 

ilciith  of,  tMir) 

flTcct  of,  u|M)n  niaiiiiiiiiry  Kiiiml,  HY.i 
of  plwrcnttil  disease  ii|hiii,  (10 

iiiuriiinificatioii  of,  (iti.j 

secrelions  of,  1(K} 

syphilis  of,  (H).") 
I'ipllicular  eolilis,  'i.'iS 

(•>sts  of  ovary,  (i'ld 

enteritis,  .'>4!l 

(lastritis,  ").'{") 

tonsillitis,  chronic,  440 
liiinites,  transmission  of  bacteria  hy,  i>0 
lool-drop,  .JOS 
I  iiruiiien  csecinn,  423 
I  iiree,  reserve,  37 
I'lireinii  bodies  in  bronchi,  44."> 
embolus,  3').< 
in  joints,  ('>il4 
in  prostate,  iVXi 
in  un'ters,  t(2;{ 
in  urethra,  t)20 
in  uterus,  G4(t 
JTiictiires,  healiuK  "f,  W^ 

of  penis,  Ki'.i 
I  r:iijilitas  ossium,  ()7(l 
I  lafiinentation  of  inyiicardiiun,  ;{!)! 
I  i:iriil)iesia,  !<S 
I  nckles,  70:{ 
I  ri'c  proteins,  25 
I  iiizinn  of  skin,  tiOS 
riicdreieh's  ataxia.  4!IS,  .")l)l 
I  iirli.-in  bodies,  Russel's,  ;{12 
I  ulriiinatin);  infection,  I4.'i 

ledetiia  of  luntjs,  447 
luiuliipii.   (irowth  and,   relationship  l)e- 

'ttceii,  M't 
I  iiiiciional  cell  activity,  3S 

diseases,  inheritance  of,  .")S 
1  uriiMcle  of  auditory  meatus,  51K 

of  skin,  700 
I'lisifiirni  aneurysm,  2!>S,  407 

liroiichiectasis,  44t) 


o 

■  M.\i  iiKi-.i.K,  2!>(),  070 

■  iliihiplidritis  purulenta,  t)07 

■  ll-lihidder,  .')!»! 

abnormalities  of,  ,")',11 
absence  of,  .^ill 
rareinonia  of,  'i!)2,  .">fW 
irraiiulomas  of,  ■)()2 
lieinorrhaKes  of,  .")i(l 
iiitlainmation  of.  r><M 
te  leriia  of.  .")ill 
sarcoma.  .">!•;{ 


Gall-bladder,  tumors  of,  .')!)2 

duct,  abnormalities  of.  .'i!)| 
atresia  of,  'Ail 
carcinoma  of.  .")".I2,  .V.t;{ 
grainilomas  of,  .'itl2 
heinorrha(!os  of,  5!tl 
intluniination  of,  ■'t'.H 
obliteration  r)f,  .")!)! 
(I'dema  of.  .">01 
sarcoma  of,  .VXi 
tiunnrs  of,  ."i!t2 
"Oallopinit  consumption."  4(12.  403 
( iallstoncs,  31.S.    Sn  also  Calculi,  biliary. 

in  peritoneum.  .">00 
(ian^lion  of  tendon  sheaths.  077 
(JanBrene,  32,S,  340 

<lrv,  330 

moist,  330 

of  skin,  700 

symme(rical,  320,  33!t 
(•aiiKrenous  appendicitis,  .V)S 

bronchit  i.s,  44.5 

intusMUsception  of  intestines,  .'>40 

stomatitis,  024 
Gartner's  duct,  cysts  of,  2S!) 
( las  embolus,  3r)2 

(iiustrie  juice,  action  of  bacteria  on,  SO 
(iastritis.  .">3") 

a<-ute,  .'>35 

atrophic,  ."»30 

chronic,  .53.5 

follicular,  53.5 

membranous,  535 

phleKmonou.s,  'hi'i 

polvjxjsa,  5;{5 
Gastro-mtcstinal  intoxications.  111 
Gaslrothoracopanus  parasiticus,  70 
Gelatin,  34 
(ienital  (jljvnfl'*.  teratoma  of,  209 

I)a.s.sa(jes,      entrance      of      bacteri.a 
through,  !K) 
Genitalia,  female,  external,  040 
(icoRraphical  ton(£ue,  524 
<i<^)tropism,  UK) 
(ierm  cell,  44 
Gerinplasm,  fusion  of,  40 

molecules  of,  40 
Gestation,  ectopic,  00(> 

interstitial,  (iOO 

tubal,  0.52 
Giant  cells,  13<J 

embolus,  3.52 

in  infective  ({ranulnmas.  140 
Giant-cellwl  myeloma,  237,  O.S(l 

sarcoma,  237,  OS!) 
(iiantism,  61,  078 

of  brea,st,  t«5S 
(iin-<lrinker'.'j  liver,  575 
GinRivitis,  ,523 
Gland-celled  carcinoma,  272 
(iland-cysts  of  brain.  402 
(danders  of  kiilney,  010 

of  larynx,  443 

of  lungs,  4()5 


wa^ 


mm. 


wrn^ 


mm. 


ri'c, 


ISUEX 


Wh 


i&^ 


(ilantlers  of  miiMclfs,  ((7.". 
of  Hose,  4;«i 
of  skin,  7(»2 
of  spleen,  4  IS 
of  Ntoniticli,  ihUi 
(ilaiuls  of  Harlholin,  cy.sty  of   tU> 
CnwiMTs,  ti;U) 

liyiHTIropliy  of,  (•oiiKcnital,  JKi 
rcKcncnilion  of,  1!H) 
M.ilivar.v,  .")2,S 
(ilaiiilular  <""ii(lotii('triti.s,  (MM 

hyiMTlrophy,  roiiKcniial,  2<W 
(iluiicoiiia,  "illi 
(Wcci,  02,S 
(ilia.  47a 
(iliorna,  24(') 

of  brain.  4!)1 

of  ptTiphcral  nerves,  mt 
of  retina.  .M.'i 
<ii"  spinal  cord,  ">()! 
(•liotnatosis.  241).  4i)l 
(iliosareoina,  2')7,  4i»2 
Gliosis,  24li,  4!tl 
(Jli.-won's  capsule,  inflammation  of.  rm 

(■lobular  thrombus,  ;{4i» 
(•lobulins,  23 
.serum,  2") 
(ilo.ssiim  inorsitans,  !M> 

palpalis,  !((i 
(ilossitis,  .")2;{ 
(jlfittis,  (rdema  of,  441 
(iluRe's  corpuscles,  4s;t 
(ilycofienic  activity  of  liver  cells   M 
(■lycoKeiious  infiltration.  MW, 
(■  ycolytic  enzymes  of  b.acteria   ,S4 
(ilyroproteins,  2.5.  .'{4  ' 

(jlycosuria.  pancreas  in.  ."i!)4 
(Joilre.  (lifTiise  parenchvmalous   4'>4 
•'xophthalmic,  101 
thyroid,  2!»1 
Conorrh.ea    |)re.lisposition  toward.   11.5 
(.onorrlueal  nifection  of  Fallopian  lubes 
o.j4  ' 

ophthalmia,  (it 
urethritis.  C2S 
(ioiit,  107,  ()77,  G94 

f.-iully  metabolism  and,  107 
predisposition  toward.  11.5 
'ophi  in.  ()i)4 

(jraftinK,  1!H».    -V'c  also  Transplantation 
(■ranular  casts,  .{12 
degeneration,  12.'i 
kidney,  small,  (114,  (ili5 
r>'iarynKitis.  4.<<) 
(iranulution.  "exuberant,"  l;{,s 

I'ssue.  12(1.  1. 5(1 
(Jranules,  Allmann's. 
of  nucleus,  22 
secretory,  22 
(Iramilomas,  infective 
of  conjunctiva, 
of  cornea,  .5 12 
of  ear,  .5 is 


;{01 


(Jranulomas,  infective,  of  Kull.bla.ldei 
of  duct,  .5i>2 
of  iris,  .512 
of  pancreas.  ,V.)ii 
of  (MTipheral  nerves,  .5<IS 
of  skin.  702 

of  spinal  cord,  4!»K.  4)H) 
of  testes,  KiH 
of  vulva,  (!4 1 
(■ravel,  bile,  ;J1<» 
in  ureters.  (i2.'j 
urinary.  317 
(■raves'  disease,  424 
(jravidic  neiiroretinitis,  i514 
(Jri.winK-point  th<'orv,  (14 
(irowiiiK  (Hjints,  braiichini?  of,  (Mi 
(■rowth,  ;i4 

■•nzyme  action  and,  30 
function  and,  relationship  bptw 

habit  of,  2N.5 
limits  of,  .3t> 

relation  to  cell  activities.  3.5 
(■uanase,  107 
(iiianin,  27,  107 

calculi,  31.S 
(iiiinea-wonn  in  skin,  703 
(Jiimma,  13.S 

of  bone,  G.S4,  0,S.5 

of  brain,  4S!» 

of  iris,  .512 

of  lunRs,  46.5 

of  mouth,  .525 

of  miLscles.  075 

of  myocardium,  3H,S 

of  i)ia-arachnoid,  ,50() 

of  skin,  701 

of  spinal  cord,  4<H»,  ri(K) 
( •.\iiccoinastia,  (MMi 


Habit,  .36 

of  KTowt  h,  285 
I  fair,  708 

rejteneration  of,  l!t5 
Hairiness,  695 
Hairy  tonRuc,  312 
Holisteresis,  6S5 
Halteridium,  9.5 
Hanot's  cirrhosi.s,  .579,  .580 
Haptines,  174 
Haptophoro,  1,57 
Hard  chancre,  630 
Harelip,  73,  522 
Hay  fever,  117,  4,3.5 
Hcalinfj  of  neoplasms,  22.3 

ulcers,  700 
Heart,  371 

arrhythmia  of,  379 

auricles  of,  371 

auriculoventricular  valves  of,  37. 

block,  378 


IXDKX 


Mi.      S,r     al 


of.     (Ii)iihlf 


ripiiM,  <liiixr<)lc'  «f,  ;{7."> 
•'iiilocariliutii     of, 

L'nijurunliiiin. 
fibrilliition  of,  ;{s(» 
intcraiiricular    septum 
oriKJii  of,  ;j,v, 

intriivfiiiriLulur  «eptuiii   of,   .Icfccis 
of,  .'ISO 

"luscl.-.    .ILseitso    of,    iilti-ration     in 

ilistnhiition  of  bl<MMi  uiul,  ;W(i 
iiiyoc'unliuin  of.    See  Mjocariliuin 
iicrvoiiN  iricdianisrii  of,  ;j77 
I>oru-ar,liurii      of,     3,S().       See     also 

rericardnini. 
poisons  artinjt  on,  S2 
rupture  of,  aoi 
seniilunur  cusps  of,  rupfurc  of,  ;j{»<) 

valves  of,  .{7(1 
septum  of,  arcessfiry  im|KTfe(  t,  ;180 

(leviatioi;  of,  .{so 
systole  of,  .{7") 
"thrush-breast,"  ,3!,() 
valves  of,  ubiioriimiities  of,  39;j 

fibrosis  of,  ,3<),s 
veRetutions  in,  34<» 
ventricles  of,  .iT.i 
flcat  discharge,  148 
priMluirtion,  IIH 
rcKulation,  148 
stroke,  78 
Kc'iiiachroinatosis  of  liver,  .57ft 
lletriannio-f'ndothejionia,  277   2S1 
of  bones,  (J8<) 
of  capilhiries,  410 
of  liver,  5.S!) 
of  pia-anichnoid,  .")(M') 
'Ii'riianKioiniis,  278 

bl;istoniut,ous,  true,  281) 
"f  capillaries,  410 
of  intestines,  ."><>0 
Heinanniosarcoma.  414 
ll('m:-,feniesis,  :i!rl 
lli'ti,.i(i,ir(,sis,  .3.54 
nciiiali!;,  2.'),  'M 

il'l|i;iloi)|;tstS,    |<»4 

II:  n^.iMcele,  ;{."i4,  titil 
ll'iiialoKenic  p:ie'im«nia,  4.51 

iuberculosi:i,  4(;4 
ll.irialoKenous  hyaline  cleKeneralion,  :jll 

'■riialohyahne  (IcKeneration,  .{11 
Miiriatoidin,  '.i'M 

liiKnicntation  due  to,  322 
i"  iriatoma,  3.54 

uFite-uter'ne,  t>61 

auris,  i5I7 

of  endof-ardiuni.  .JO.'j 

iii!raliKa;iientous,  fitil 

of  muscles,  U7) 


727 


post-uterine,  Oiil 

•>f  vulva,  (Ul 
'■•liatometra,  tl4(i 
^ii.itopi.ri.-ardium,  3.51,  .382 
;i';-"o|.orphyrin.  piKmentalion  due  lo, 


Heniato.sjiIpinx,  (5.5.3 
Meiiialos|M)ridia,  (»7 
llemalolhorax,  3.54,  4ti»i 
Hemalozoon  inalaria-,  !t7 
Hematuria.  .3.54,  t>03 
Hemiccphaly,  72 

Hemochromatosis,  322,  4 IK,  579,  7ft3 
Hemoclastics,  HI 
Hemoeonia,  3()6 
Hemofuchsin  in  liver,  .322.  .58() 
HenioKlobin,  coHi|M)sitiiMi  of  24   ''.5 
imbibition,  322,  .3.5(1  '  ~ 

in  endocardium,  3i).3 
pinnienlation  due  to,  .321,  322 
variations  in,  .3,5i» 
Hemonlobinuria.  .322,  (MM 
HemohepatoRenous  jaundice,  324 
Hemolymph  nodes    1 1  I 
Hemolysis,  KM,  .3,51) 
Hemolytic  splenomcKaly.  241    .57<» 
llemolytics,  81 
Jlcmophilia,  47,  3.5(» 
Hemoptysis,  3,54 
Hemorrfiage,  3.54 
cerebral,  4<»8 
etTects  of,  3.5.5 
in  luHK,  448 

[H'r  diaiMHlesin,  33il,  ,3")4 
per  rhexin,  339,  3.54 
retinal,  .510 
in  typhoid  fever,  .5.5.3 
Hemorrhauic  cysts.  287,  293,  3.50 
of  brain.  492 
of  mammarv  uland,  (507 
enceiihalitis,  488 
endometritis,  ti47 
erosions  of  stomach   .5.34 
infarct,  344 

of  intestines,  .547 
inflammation,  1.34 
mo'e,  212 
nephritis,  (il2 
otitis  media,  .518 
pancreatitis,  .59.5 
IM-rittmitis,  .5(5.3 
I'lLiirisy,  469 
retinitis.  .514 
sei.ticemia,  91 
Hemorrhoid,  278,  .547 
Hemosiderin,  .3.5t) 
in  liver,  .58(5 

pigmentation  due  to,  32'.' 
Hepar  lobatum,  583 
Hepatiti.-;,  .573 
acut»',  573 
suppurative,  .574 
Hepatization  of  limR,  4.52 
Hepatolysin.  16.3 
Heredit.y,  46 

variation  and,  47 
Ifennaphroditi.sm,  74 
lleriMa.  .568 

abdominal,  .569 
epiRn-stric,  .5(50 


i>^dt:<uxe^^S»^. 


Nk  -i 


rS,}'-y. 


.Vis 


.'iti'.l 


rt><<).  (Mi.". 


72S 

lloniia     li:iplir!i)tin;ilic,  .'ti't 

••M    .ii.il,  .'ids 
ft'inoriil.  .Vi!) 

iiicarrcratiiin  of, 

iiiKiiin.'tl,  .'i(i.s 
iliri'ct,  MM 
incoinpli'tr, 
<>hli(|iii',  M)S 

iiitornal,  .'rti.s,  ."iti!! 

<>l>Mirator,  .">ii!i 

IH'riiical.  "iti!) 

n'(liiril>|c,  Mis 

.xfiatic,  ."i(ii( 

fiTotal.  .">()!» 

iiinliilical.  72, 

vaKinal.  .'i)i!) 
McriM's,  (iO.H 

of  corm-a,  .">12 

fai'iali.'*,  ti!»,s 

lahialis,  .V2;{ 

pn'imtialis,  (i!l(» 

priiucnilalis.  tl:!ll 

of  >kin,  (><>.s 

zi'.-^tcr,  V22.  ;f7(l,  till.s 
MctcriK'htlionoiis  blaslofiia.s.  .'2;! 
Hftcrolvsiii,  l(i;{ 
Hclcruly.si.s,  |(M> 
H(>t(T()<)|)lial  twins,  ti2 
Hctcropla.siii,  2(»:{ 
Hctcroplastif  n.stcoiiia,  2.J,") 

lraii.-«plaiit:iti<in,  l<)<) 
Hciirotopia,  2l).i,  4.S(i 
Hetcroiopic  livpcrncphroiiia.x,  277 
Hip,  cotiKcnituI  <li.s|.)calir)ii  of,  (i'K),  G!(l 
"Mip-joitil  (li.sca-ic, "  (i,s4,  <><.(.( 
flir-cli-piutiK's  (li-ic;i.sc,  .MJ.  .-)li2 
Hi.'siiiics.  (i!».') 
Hi.s,  hundlp  of,  377 
Histolvsi.s,  normal,  2!(r. 
ri.l.r.Mlliv.T.  .->7.-. 
.'iHl(jkiir-i  (li.scasc.  S.i'.K   11.; 
HdH-hack  kiiliK'v,  t)l;j 
Iloinophustic    istcoiiiji,  2.'f.") 
MoMiotropisiii.  201 
H<irrn.inp»,  KM) 
Horn-,  oulancoii.s,  2")!l,  7();i, 
Horseshoe  ailrcnals.  421 

kidney.  •>()> 
Hott(.ntot  apron,  •)4() 
HoiirRla.'^s  sloniai  'i. 
"  Ffou-scniaiil'    km. 

Hutch. lIMill'.S  tcclli, 

M valine  easts,  ;}12 

(•(lis,  -.uy.] 

niononiielear.  i:i2 
clianRe  in  niyoe.irdinin,  V.i] 

in  ov.'iry,  ().")t'i 
deiii'iM'r.'ion,  I2:i,  :W,.  :■(()» 

':!'  .art  cries,  401 

of  ciipill.-iries,  410 

of  kidtiey,  (120 

of  IvMiph  nodes,  413 

"I  >,.()slale,  ("'! 

of  i!i\roid  kI.hkI   424 


1).". 


■  ti 

■'7, 


rs 
r,->:i 


J.SDKX 

Hyaline  deiMisii,  3iMi 
("•inai.  .'c'tioiis,  .'{|  1 
iii.'illralion  of  capillaries,   tlO 
nioiio'iilelear  eell,  131,  l.!2 
throi'ihiis,  317 
Myalo-eiH'hundronia.  231 
ilyalo.-'erosilis  o(  liver,  jSl 
ill  peritonitis.  M;r> 
in  pleurisy,  -tti't 
Hydatid  cysts*,  2!i.'. 

of  liver,  .llHI 
eeliinoco<'cus.  2!I4 
of  .MorKaniii,  2S!I.  (i."),i 
mole,  212 
Hydatirlifnrm  mole  ot  pl.'.ceiila,  (Kit 
Hydraniniii.-.  (il,  t>(i."> 
Hydiemia.  3;{.">,  3,'i7 

of  hliHid  pli4sma,  3,".7 
plelliora.  .33.") 
Hylic  ti.ssucs,  22.") 
HydnK-elc,  .ititi,  (WO 
cervical,  2.S1 
cncystiil,  2X0 
of  fourth  ventricle,  202 
.scrotal,  2'Jl 

of  tunica  vaisinali.s  testis,  (13(1 
Hydrocephalus,  01,  202,  3(1(1,  4.S0,  40,") 
Hydrolysis,  enzyme  action  and,  .32 
Hydrometra,  201.  04() 
Hydroniyelia,  40.") 
Hydronei)hrosis,  77,  203 

from  kinks  in  ureters,  (123 
Hydropericardiiim     iiiO,  3S1 
Hydropic  dr'ueneraiion,  3(Mi 
H.vdropncumothorax,  407 
H\(lro|)s  cvstidis  fcllea',  .".02 
ex  vacuo,  200,  .304,  371 
vesi.a'  fcllea',  2!«) 
Hydrosalpinx,  2iH>,  (l,"i4 
Hydrothorax,  .330,  300,  370,  1(1(1 

chylous,  4(17 
Hyuroina,  202 
of  burse,  07.^ 
colli,  202,  411 
cystic,  2S1 
of  necl;,  307 
of  orbit,  ,")17 
of  tendon  sheath,  (177 
Hylic  neoplusm.s,  22.1,  226 

tumors,      typical,     of     me.sotliclial 
oritjin,  213 
Hylomas,  220 
Hymen,  (141 
absent,  041 
itTiperforate,  041 
Hypamnio.s,  01 
Hyphomyce^'s  of  hin({s,  10.') 

j)atlioKenic,  02 
Hypisotonic  solutions,  o.smosis  and,  .l.f 
Hyperemia,  337 
active,  337 
of  a<henals,  422 
of  bladder,  02.") 
o/  bone  marrow,  410 


IShKX 


•29 


MJ 


:{.{.s 


lly[MTPmia  of  hi>tir.i.  ti7!» 
of  liraiii,  tsti 
ciipilliirv,  X\S 
of  ciioroiil,  .'iltt 
no  Hal  I  Til,  :i;i7 
of  ciinjurirtiva.  .'»()1l 
^     rl.  ,{;{7 

t'allopiuii  tiilH-M.  ti.'k't 
of  rris,  ".III 
of  kidiii  s    .Ml'* 
of  iiilcsliiH's,  .jKi 
of  larviix,  441 
of  liver,  oTO 
of  luiiKN.  117 
of  lymph  iio<l('.' 
uf  iiioilth,  '>2:i 
of  inusclox,  ()7:{ 
ni'iiroparalylii  . 
ncurutonic,  ;i;i.s 
of  iiosi',  4.{4 
of  paiicrcaH,  oil.") 
of  |M>riton(Miiii,  .>(i2 
of  pharynx,  4;{7 
of  pia-iirachnoiil,  ."><ll 
of  placenta,  (Mil 
of  pleura',  4()(> 
of  prostate,  i\'X\ 
of  retina,  ."illl 
•■r  ■'  111,  tilHJ 
Hi    |.|een,  41."» 
of  stomach,  .VW 
of  t<m!fil.s,  4;{7 
of  uterus,  040 
venous,  :v.iX 
ll>pere.s|hesi;i,  47!l 
II'.  periiiosis,  ;{4.S,  :{."i,S 
ll,\  perisotoiiic  sdliilions,  osmosis 
li\perkerato.»is,  'ioll,  :\\2 
llvpernephronias,  270,  277 
of  ailreii.'ils,  42;{ 
of  hniin,  4!I2 
of  kidnev,  021 
"f  liv<'r,  oSO 
l\|h  lostoses,  (l(;ntal,  .527 
!lypi|-pl;i.siu,  ISO 
of  adrenals,  422 
of  l)oiu'  marrov,  41'.l 
uf  holies,  'i^O,  tiS.S 

»'•    clit;OPS,    040 

irrit:iti\(',  2t>;{ 

of  lymph  nodes,  4i;{ 

of  parathyroids,  420 

of  sph'en,  41.S 

of  testes,  t>:{!l 

of  thymus,  472 
Ivpirthyroiilism,  424 
1^  iicitomis,  AK\ 
iM'crlrichosis,  02,  0!».">,  70S 
lv|iirlrophic  eirrho.-is.  ">70 

iliiiiilis,  4.'!.") 
l\|"rlrophy.  3S,  ISO 

acroi.iejj.'ily  ,'ind,   1S<I 

■■id;iptivr    i,'s7 

of  .-iiierii'S.    lilll 


and,  XS 


My[H'rl,rophy  of  liladder,  020 

eomiK'iisalory.  ISS 
of  testes,  0;{!» 

conKeiiital  Klandiilar,  20;i 

of  heart.  HIM 

of  inleslines,  ."kiO 

irritative,  l.SS 

of  kidnev,  l>20 

of  liver,  ".").S!I 

of  muscles,  070 

of  inyiM-ardiiim,  ;t.S."i,  :{'.)! 

nutritional,  IS8 

phy.siolofcical,  1H7 

of  prr>slate,  0.'{4 

.simiilatol,  IS!) 

sympathetic,  IS'.I 

of  uterine  liKuments,  ti02 

of  uterus,  O.jO 

vicarious,  !S,S 
Hypinosis,  :{47,  ;{">H 
llypobla-Ml,  22:i 

MyiKihlustic  neoplasms,  22."(,  220 
llypoKcncsis,  polar,  70,  71 
Hypophysis  cerebri.    Ni«  I'iliiilarv  hodv. 
Hy|K>plitsia,  70,  2!IS 

of  adrenals,  42 1 

of  arteries,  400 

of  larynx,  440 

of  mamie-iry  k'h'"!.  •>'">•> 

of  myocardium,  :fs.") 

of  ovaries,  O.V1 

of  pancreas,  .")94 

of  testis,  0;{7 

of  thyroid  Kland,  424 

of  uterus,  04;{ 
Hypopliistie  penis,  i\M) 

unilateral,  prostate,  ftXi 
Hypopyon,  .512 
Hypospadias,  (57,  02S 
HyiKistatie  congestion  of  luncs,  147 

pneumonia,  4.52.  4.57 
Hypothyroidism,  421 
iIy|M)xanthin,  27,  107 
Hysterical  paralysis,  4.S3 
Hysterocele,  044 


IcilTnvoai.'<,  312,  00.5 
Icing  liver,  .5t).5,  .5S1 
Icterus.    .Sec  .(aundice. 
ldiosyncra.sy,  1 17 
Imbibition,  hemoKlobiii,  ;{22 
Immune  boily,  104 

serum,  11)4 
Immunity,  1.52 
ab.solnte,  1.52 
acquirefl,  U.5,  110 
.ajjainst  abrin,  l.<4,  1.5.5 

albuminoid    venettible    poi.sons, 

1.54 
enzynn's,  li5.5 
phytotoxin,  1.54 


■HB 


ma 


MICROCOPY    RESOLUTION   TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No^  2) 


1.0 


I.I 


1.25 


•flllM 
t  1^ 


1.4 


2.5 


12.0 


1.8 


1.6 


A  APPLIED  IIVMGE     Inc 

=^  16^!   [051    Mo'"   SUeet 

r«S  'Rochester.    New    lorh  M609        'JSA 

JS  .,  '16)    48.^  -  0300  -  Phone 

^=  me)   288  -  ^989  -  Fq« 


r.'U) 


IXDKX 


Immunity  apainst  riciii,  154,  1.") 
robin,  154,  155 

Muhstanccs  of  known   constitu- 
tion, 15l{ 
of    unknown    conslitution, 
155. 
anapliylaxis  an<l,  170 
Khriioir.s  theory  of,  157   KiO,  172 
familial,  115 
non-sppcific,  152 
passive,  154 
relative,  152 

sidiMihain  theory  of,  157-100,  172 
theory  of,  172 
I mperfeet   closure  of  anterior  hodv  sur- 
face, 72 
of  hratichial  clefts,  74 
of  dorsal  tiroove,  71 
of  facial  clefts,  7:5 
Imperforate  hymen,  ()41 
Impctitso,  (iiHt 
Implantation,  19!) 
cysts,  21):?,  707 
Inactivated  scrum,  lt)4 
Incarceration  of  hernia,  5f)S 
Inclusions,  abdominal,  20!> 

dermoids  of  pia-arachnoid,  5(Mi 
fci'tal,  20S 
Incompetence  of  lieart  valves,  ;}*17 
Incomplete  iufiuinal  hernia,  5(>!( 
Incontinence  of  urine,  (105 
Incrustations,  calcareous,  ;{15 
Incubation  period  of  infection,  144 
Individual  inheritance,  4,S 
Indol,  consti)ation  and,  HI 
Indolent  bubo,  ti^U 

ulcers,  700 
Induration,  "brown,"  of  lunns,  44S 
in  pneiunonia,  45S 
cyanotic,  of  kidney,  tiO'.l 

of  lungs,  44S 
mediastinopericardit  i? ,  ;W4 
Inchirative  pnemnonia,  secondary,  457 
Inertia,  physiological,  ;{•> 
Infantile  scurvv,  tiSS 
Infarct,  a2S,  ;i41,  M-i 
of  ailrenals,  422 
anemic,  344 
of  bones,  ()7i' 
forn>:ition  of,  'M'.i,  ."UCi 
liemorrliagic,  ;{44 

of  intestines,  547 
of  liver,  572 
in  lungs,  44S 
of  muscles,  (i74 
necrosis  and,  ;V2S 
of  phu'cnla,  t)('i4 
red,  :i44 
results  of,  il45 
uric  acid,  1117 
white,  ;{44 

of  liver,  572 
Infarction,  ;{1^! 


141 

4!! 


Si) 
ui,  141. 


Infe 


•tions.  .!<! 


14:!. 


Infections,  acute,  14() 
chronic,  141) 
complications  of, 
continued  febrili 
course  of,  14:i 
crisis  in,  140 
"cryi)togenic, 
defervescence  in,  141.  14(1 
endemic,  14:5 
enzootic,  14:1 
epidemic,  14:i 
epizootic,  14:i 
exacerbation  of,  I  lt'> 
fastigium  in,  144 
febrile  state  in,  144 
fcrvi'.scence  in,  144,  14!) 
fevi  r  in,  continui  1,  144 
fulminating,  145 
grades  of,  1 15 
incubation  period  of,  144 
lat.nt,  121,  14t) 
localized,  145 
lysis  in,  140 
meta.stas(w  in,  145 
m(Mles  of,  SS 
])ersisting,  14t> 

premonitory  symptoms  in,  144 
prodromal  symptoms  iti,  144 
pyrogenetic,  14!) 
remittent,  146 
se(|ueUe  of,  144 
of  spinal  cord,  4!)t) 
sporadic,  14:5 
stages  of,  14() 
terminal,  121,  147 
wound,  SO 
Infectious  albuminuria,  60:i 
Infective  granidomas,  i;{S 

thrombosis  of  dura  mater,  .")0I 
Infiltrations,  :{(M) 
of  arteries,  401 
of  cai)illaries,  410 
"fatty,"  ;J()2 
glycogonous,  ;}0*> 
lipoid,  :>l)5 
of  liv(>r,  5S4 
of  lymph  no<les,  41?! 
of  myocardium.  ;!SS 
of  pancreas,  .507 
of  spleen.  41S 
Inflammation,  IIS 
of  adrenals,  422 
Bacillus  typhosus  and,  12i 
of  bladder,  025 
blood  cells  in,  128 
of  bone  marrow,  41!) 
of  bones,  OSO 
of  brain,  4SS 
of  bronchi,  444 
of  bursir,  07S 
cau.ses  of,  120 
catarrhal,  \'M 
cell  proliferation  .and,  11!) 
cliemiot.ixis  and.  1 1!) 


INDEX 


r.M 


Inflammation  of  choroid,  513 
chronic,  13;) 
of  ciliary  body,  512 
of  conjunctiva,  510 
of  cornea,  511 
of  Cowppr's  glands,  (iU6 
diffuse,  141 

of  drum  membrane,  51 H 
of  dura  mater,  502 
of  ear,  51S 

endothelium  of  binodveswels  and, 
eosmophiles  in,  129 
exudate  in,  134 
of  eye,  510 

of  I'aliopian  tubes,  053 
fibrinopurulent,  134 
fibrinous,  134 
fibrosis  and,  142 
fixe<l  tissues  and,  131 
of  Kail-bladder,  5(tl 

-<luct,  591 
hemorrhagic,  134 
of  intestines,  54S 
of  iris,  512 
of  joints,  691 
of  kidney,  609 
of  larynx,  441 
of  liver,  575 
of  lungs,  450 
of  lymph  nodes,  412 
of  lymphatic  vessels,  411 
lymphocytes  in,  128 
of  mammary  gland,  iV 
of  mediastinum,  470 
membrane  in,  !34 
of  middle  ear,  518,  520 
of  month,  523 
mucopurulent,  134 
of  mucous  surface,  133 
of  muscles,  674 
of  nails,  708 
necrotic,  134 
of  non-vascular  area,  134 
of  nose,  435 
of  (esophagus,  531 
of  optic  nerve,  517 
of  orbit,  517 
of  ovary,  655 
of  pancreas,  595 
•if  penis,  630 
of  p(>riphpral  nerves,  507 
of  peritoneum,  ■")63 
of  pharynx,  437 
phlegmonous,  134 
of  pia-arachnoid,  504 
of  placenta,  064 
of  pleune,  467 

polynuclear  leukocytes  in,  128 
purulent,  134 
of  retina,  513 
serofibrinous,  134 
seropurulent,  134 
"f  skin,  696 
of  spermatic  cord,  640 


Inflammation  of  spinal  cord,  4!i5 
of  spleen,  417 

Staphylococcus  pyogenes  and,  121 
of  stomach,  535 
of  teeth,  526,  527 
of  tendon  sheaths,  ♦)76 
of  tendons,  t)70 
of  testes,  0;« 
of  thyroid  giand,  424 
of  ton.sils,  437 
127  of  tunica  vaginalis  testis,  OJJO 

ulcerative,  134 
of  ureters,  623 
of  urethra,  628 
of  uterine  ligaments,  661 
of  uterus,  047 
of  vagina,  642 
of  vas  deferens,  640 
j  in  vascular  area,  123 

I  of  vulva,  641 

of  veins,  410 
wandering  cells  and,  1 19 
Inflammatory  fibrosis    142 
a'dema,  370,  447 
tumors,  207 
Infusoria,  ciliate,  97 
Ingrowing  toe-na  :.  708 
Inguinal  hernia,  .50.S 
Inhalation  pn'>umonia.  4.")0 
Iidiibitive    poi.sons   acting   on    muscular 

system,  81 
Inheritance,  40.    Sie  also  Heredity. 

of  .abnormalities  from  previous  gen- 
erations, 57 
of  acquired  characters,  .53 
I  "anti.specific"  characters  and,  57 

atavistic,  48,  50 
i  blended,  48 

I  cumulative,  .50 

i         familial,  47 
i  forms  of,  47 

of  functional  di.se!i.«es,  58 
of  hypospadias,  57 
individtial,  48 
I  Mendel's  law  of,  48 

j  normal,  51 

;  non-,  51 

i  " panuspecific "  cpialities  and,  57 

1  parental,  48 

'  particulate,  48 

I         of  polydactylisni,  57 
I  progressive,  51 

I  racial,  17 

retrogressive,  51 
reversionary,  .50,  51 
theory  of,  51 
Inherited  disease,  55 

pathological  states,  .56 
pre<lisiK)sition,  115 
Iniencephaly,  72 

Inoculation,  cells  of  tumors  and,  287 
Insecfa.  98,  KM) 

In.sects,  transmission  of  bacteria  by,  TO 
of  Kporoz'>?»  by,  97 


m 


n! 


7:?2 


IXDKX 


Inspissalioti  in  H!iiij!i <'ni',  -i'M 

uriitic,  ill  infiiiH'y,  1517 
Intciilidii  tremor,  4S4 
Intcnmricular  septum   i>f   liear*     double 

oritiiu  of.  ■<><•) 
liilerciirreiit  relapse,  14t) 
lliteriuediate  body,  HU 
Interniitteiit  fever,  14'.l 
Iiiternid  seeretious,  KM),  2Hi 
Interstitial  einpliysema,  4r)ll 
eiKlometritis,  t)4S 
fibrosis  of  liin(js,  4(i") 
myocarditis,  :}S7 
n«M)hritis,  tiOC),  tU4,  (iKi 
ledeina,  :iti(i 
Intertrigo.  (')!•!> 
Interventricular  septum  of  Iieart.  defects 

of,  :{S(> 
Intestinal  bacteria,  .S."( 

tract,  entrance  of  l)acteria  tliroufjh, 
•H) 
secretions  of.  lO^i 
Intestines,  al)norinalities  of,  .'>44 
atresia  of,  .")44 
anemia  of.  .">4() 
carcinoma  of,  .")(">() 
cysts  of,  r)44 
dilatation  of,  •")I."> 

diseases  related  to  secret iohs  of,  1'):? 
diverticula  of,  .")4.") 
fibroma  of,  .")()0 
liemaiittioma  of,  "itWt 
IiemoirhaRe  of,  .")47 

occult,  .")47 
hemorrhanie  infarcts  of.  '>i~ 
hyperemia  of,  .")4() 
hypertrophy  of,  ")(>(• 
iiitlammation  of,  .■)4S 
inttissuseeption  of,  .")4.") 

Ranurciious,  r)4t) 
invagination  of,  .")4.") 
large,  ■■j41 
lipoma  of,  .">(>() 
lym))lian(jioma  of,  otlO 
lymjihosarcoma  of,  .")<>! 
myoma  of,  ."lOO 
papilloma  of,  ■")<>(• 
poisons  ai'ting  on.  S2 
.sarcoma  of,  atil 
small,  .■)41 
stenosis  of,  .")44 
strangulation  of,  .")4.5 
syphilis  of,  .">.").") 
tuberculosis  of,  ,j.")l{-.').')."i 
tumors  of.  .")()() 
typhoid  fever  and,  •")4'.) 
idi<'r  of.  .")4S 
varices  of,  ,")47 
volvulus  of,  .')4.") 
Intoxicatir)n.  .">!<.  70.  14.") 
bacterial.  S.") 

•distinction   o''     from   infection, 
S,") 
disintegrative,  St),  Id.') 


Intoxication  due  to  non-eliminated  iinxl- 
ucts  of  kalabolism,  104 
to  resorption  of  excretions,  1(1,') 
endogenous,  7i<.  1(H) 
exogenous,  7!<,  .M 
ga.stro-intestinal.  111 
internal  .secretory,  7!) 
intra-uterine,  us  cause  of  disease,  .")!! 
ni;  tabolic,  HO 
iion-para.sitie,  7!t,  .SO 
parasitic,  79,  .S4 
sapremic,  145 
saprophytic,  71) 
Ii.cracanalicular  fibro-adenoniu  of  mam- 
mary gland,  (>70 
Intracellular  enzymes,  2S 

fat  aecunnilations,  ;{()2 
Intracystic  jiapillomas,  "ifil 
Intraligamentous  hematoma,  (iOl 

myoma  of  uterus,  ().50 
Intramural  myoma  of  uterus,  (')">() 
Intra-uterine  cauf'<  of  disea.=e,  .'J.S 
Intussusception,  .")4.") 
Invagination  of  intestines,  .")4.'),  'Aii 
Inversion  of  uterus,  ()4"» 
Involucruni  of  bone,  OM) 
Invt)lution  cysts  of  niaiiniary  gland,  f)7() 
Ionization,  water  and,  ;{2 
lodothyrin,  100 
Iridocv<'lilis,  .512 
Iris,  a)).sence  of,  509 
gumma  of,  512 
hyperemia  of,  510 
infective  granuloma  of,  512 
inHamniation  of,  512 
pigment  of,  absence  of,  509 
sarcoma  of,  515 
.syphilis  of,  512 
tubercle  of,  512 
tumors  of,  515 
Irritation,  definition  of,  ll.S 
grades  of,  122 
local  reaction  to,  118 
Irritative  hypertroi)hy,  188 

])oisons  acting  on  muscular  sy^lciii, 
81 
Ischemia,  ^{115 
I.solvsin.  !(>:{ 
Isoplastic  transplantation,  199,  201 


.Iacksoman  convulsions,  482 

.Iaiiice|)S,  (18 

,Iaundice,  :}4.3,  703 

catarrhal,  :VZ.i.  .")'H 
hemolieputogeih    is,  324 
obstructive,  lO-'i,   '>'-.i 
skin  in,  703 

.lejuinmi,  .541 

,Ioints,  (190 

.abnormalities  of.  (190 
ankylosis  of,  091 


ISDEX 


73.S 


.loiiits,  atrophy  of,  1>'.I4 
ciiricts  of,  tiiCJ 
"Charcot's,"  »)!)4 
corpora  oryzo'uica  of,  0'.(4 
fon.'inii  bodies  in,  W)4 
heinorrhajffi  of.  •>'.•! 
inHatiirnatioii  of,  ti'.M 
H|>oina  arborcscciis  of,  (>!(") 
nu'taplusia  of,  l>'.)') 
ochronosis  of,  ti04 
ostco-arthritis  of,  O'.tl 
sarcoma  of,  tiit.'i 
subluxation  of,  G!>1 
syphilis  of,  ()!)."{ 
tuberculosis  of,  (jtKJ 
tumors  of,  (>!)."> 


Kala    azar,     Le  simian-Donovan    ImmIIc.- 

and,  !».5 
Karyokinctic  cell  division,  13.S 
Karyolysis,  23 
Karyorrhexis,  23 
Kiitabiosis,  3.5 

Katabiotic  activities  of  cell,  3.5 
Katabolism,  elTects  of  pnxiucls  of,  104 

non-eliminated  i)roducts  of,   intoxi- 
cations due  to,  104 
Katadidyinus,  (>7 

K;.talvt=is,  action  of  eiizvnies  bv,  2S 
Kat  aplasia,  2!»9 
Kailiions,  32 
Keloid  of  skin,  705 
Ke|)lialin,  27 
Keratin,  312 
Keralinization  in  carcinoma,  270 

pathological,  312 
Keratitis,  511 

parenchymatous,  diffuse,  511 

piilyctenular,  512 

suppurative,  512 
Kcratohyaline,  312 
Ki'ratosis  of  penis,  632 
Ki  Iney,  (iOS 

abnormalities  of,  tills 

absence  of,  tiOS 

actinomycosis  of,  (il!) 

adenoma  of,  ()21 

amyloid  of,  (V20 

aiiemii'  of,  tiOS 

angioma  of,  ()21 

anomalies  in  shape  of,  t>0,S 

atrophy  of,  til 7 

bacteria  in,  .HS 

carcinoma  of,  (i21 

cloudy  swelliuK  of,  tl20 

congenital  cvstic,  2S'.( 

cysts  of,  Ii22 

dcfjencration  of,  ()20 

embolism  of,  tiO'.t 

(ibronias  of,  1121 

filial  lobulation  of,  (iO.S 


Kiilney,  ulatiilers  f>f,  (iPI 

granular,  small,  til 4,  1)15 

hog-back,  til 3 

hors('-slioe,  tiOS 

hyperemia,  liO!) 

hypernephroma  of,  (i2l 

hypertrophy  of,  020 

ii  ciuration  of,  cyanotic,  t>it!) 

inflammation  of,  tiOO 

large  mottled,  Iil2 
red,  Iil2 
white,  til 2 

leprosy  of,  til'.l 

lipomas  of,  liJl 

mobility  of,  tHlH 

myoniiis  of,  Ii21 

myxomas  of,  t)21 

nerve  supi)ly  of.  ti(M) 

pelvis,  disturbances  of,  ti22 

pigments  in,  <i2t) 

Ijoisons  acting  on,  s4 

regeneration  of.  l!ll,  100 

sarcoma  of,  02 1 

"surgical,"  tiI7 

syphilis  of,  Olit 

telangiectasis  of,  021 

teratobliisloma  of,  021 

thrombosis  of,  (itIO 

tuberculosis  of,  OlS 

tumors  of,  275,  ti21 

unilateral,  litis 

uric  acid  in,  ti20 

va^cular  supply  of,  000 
Kink  of  ureter,  023 
Knee,  "white  swelling"  of,  OSl,  1)03 
Koplik's  .sign,  .523 
Kraurosis  vulva-,  041 
KuplTer"s  star  cells,  .5Sli 
Kyphosis,  0S3 


Labia,  Mi) 

abnormalities  of,  till) 

(edema  of,  041 
Labor,  premature,  causes  of,  liO 
Labyrinthitis,  510 
Lacrimal  concrements.  315 
Liennec's  cirrhosis  of  liver,  575 
Lacing-lobe  in  liver,  .").S4 
"Laking"  of  bloo<l,  3liO 
Larvngiti-    140 
"acute,  441 

catarrhal,  441 

chronic,  442 

membranous,  441 

phlegmonous,  442 

syphilitic,  443 

tuberculous,  442 
Larynx,  42S,  440 

abnormalities  of,  440 

absence  of,  440 

actinomycosis  of,  443 


ill  II 


734 


INDEX 


Larynx,  lulciioiim  of,  4415 

itItiTatioii  in  sizo  luul  slmi>o  of,  444 

iiiicinia  of,  441 

at  rcsia  of,  440,  444 

atrophy  of,  443 

carciiioiiia  of,  443 

cysts  of,  443 

enchondroma  of,  443 

Kbroina  of,  443 

fissuri'il,  440 

fistula  of,  440 

ulanders  of,  443 

liy|M)pl:u<ia  of,  440 

iiiflaninmtion  of,  441 

hypcrfniia  of,  4  1 1 

leprosy  of,  443 

lipoma  of,  443 

liinion  of,  obstni'  tion  of,  444 

1\  ■nphaiiicioina  of,  443 

iiiyxoiiia  of,  443 

papilloma  of,  443 

rhinosclrroma  of,  443 

sarcoma  of,  444 

tumors  of,  443 
Latent  infection,  121,  14() 
l.atcral  sclerosis,  amyotrophic,  49!) 

family  tyi)c  of,  4!)'J 
Lathvrism,  501 
"Laudable  pus,"  138 
Lead  neuritis,  .^OS 

poisoiiin)!,  blue  line  in,  32o 

peripheral  nerves  and,  508 
pigmentation  and,  325 
Lecithin,  27,  34 
Leiomyoma,  241 

of  vagina,  t)43 
Leishman-Donovan  bodies,  "K") 
Lens.  515 

dislocation  of,  50!) 

opacity  of,  500,  515 
Lepidic  tumors,  220,  257 
Lepidomas,  220,  257 

transitional,  274 
Lepra,  701,  702 
Leprosy,  ,508 

of  bone,  t)85 

of  brain,  400 

:)f  conjunctiva,  511 

of  kidney,  (ilO 

of  larynx,  443 

of  nose,  430 

of  periiiheral  nerves.  .508 

of  pleura,  407 

of  skin,  701 

of  spleen.  118 
I>eprous  nodules  of  mouth,  .525 
Leptomeningitis,  .504 
Leucorrhea.  043,  t>47 
Leukemia,  304 

lymphatic,  240.  305,  414 
m>el<)gen<ms,  238,  305 
Leukocytes,  3li2 

action  of.  on  bttcti'riii,  87 

enzymes  of,  100 


leukocytes,  granular,  302 
neutrophile,  302 
|K)lynior|)'ionuclear,  302 
;         |K)lynuclear,  302 
I  in  inflammation,  128 

\  regeneration  of,  li)4 

'  Leukocytosis,  304 
alimentary,  304 
polynuclear,  .364 
terminal,  304 
Leukoderma,  005,  703 
Leukolysin,  103 
Leukolytics,  81 
Leukopathia,  708 
Leukoplakia,  312,  524 
of  nails,  708 
of  U'sophagus,  531 
Leukoprot  cases,  10<) 
,  Lichen,  690 
i         scrofulosum,  099 
;  Liebermeistcr's  grooves  of  liver,  570,  584 
'  Life-cycles  in  sporozoa,  90 
Ligaments,  uterine,  661 
\  Light  as  cause  of  disease,  77 
Lines!  albicantes,  703 
Linin,  18 

Lip,  median  cleft  of,  522 
I  Lipases,  34 
Lipemia,  358 

of  blood  plasma,  358 
Lipochondroma  of  peritoneum,  567 
Lipochromes,  27,  34 

pigmentation  due  to,  324 
Lipoid  degeneration,  305 

infiltration,  305 
i  Lipoids,  24,  26 
Liixilytic  ferment,  34 
Lipoma,  233 
I         arborescens  of  joints,  695 

of  bronchi,  446 
i         of  conjunctiva,  515 

of  ear,  521 
i  of  intestines.  560 

i         of  kidney,  021 
of  larynx,  443 
of  lungs,  465 
of  mouth,  525,  .520 
niyxomatodes,  232,  2.33 
of  peritoneum,  .567 
of  a'sophagus,  .531 
of  penis.  633 
of  peripheral  nerves,  509 
of  peritoneum,  567 
of  pia-arachnoid,  .506 
of  pleura,  470 
I  of  stomach,  .539 

I  of  tendon  sheaths,  677 

of  uterine  ligaments,  662 
of  uterus.  6.50 
of  vulva,  642 
Li|H)matoid  growth,  2.3.3 
Lijiomatosis,  62,  2'^3,  705 
Liposarcoma,  2.5I> 
Liquefaction  of  vitreous  humor,  516 


INDEX 


'.•55 


l.ilhiiisis,  iiriiiiiry,  'Mi\ 
Litliopadicjii,  ;{l"4,  5G»>,  (jtM 
I-ivcr,  5«!»,  570 

ubnorinulitips  of,  570 

acco.sMory  lobes  of,  570 

iicfinoiiiycosis  of,  5K;{ 

udciiotna  of,  5S!I 

iiiiKi-bic  abscesM  of,  575 

niiiyloid  of,  .5,S5 

anemia  of,  570 

Asraris  liimbricoidps  in,  .5i)0 

atropliy  of,  5h;{ 

brown,  .5H;J,  5S(i 
red,  arutr,  574,  5.Sij 
Vi'llow,  acute,  571 

autolysis  of,  1(M» 

calcification  of,  ."jXti 

carcinoma  of,  ■5,'S!» 

cardiac  depression  in,  5.S4 

cavernoma  of,  5S<) 

cell  embolus,  ;{,")2 

KlycoKPTiic  :i.;livitv  of,  ;il 
cirrhosis  of,  .575 
cloudy  swelling  of,  ,5S4 
coccidiosis,  5!K) 
congestion  .if,  passixe,  570 
cyanotic  induration  of,  572 
cysts  of,  5!M) 
degenerations  of,  5S4 
distomum  in,  590 
emboli  of,  .573 
fibroma  of,  .589 
focal  necrosis  of,  573 
giri-drinker's,  .575 
Gli^sson's  capsule  of,  inflammation  of, 

•)H1 

liemangio-cndothelioma  of,  589 

hemofuchsin  in,  .586 

hemorrhage  of,  .573 

hemosiderin  in,  .586 

hobnail,  575 

hy.'i'oscrositis  of,  .581 

hy,    -eniia  of,  570 

liyiHi-ncphroma  of,  ,589 

\\\  pcrtrophy  of,  .589 

ic  ng,  .581 

in  icterus,  .586 

infarct  of,  572 

infiltrations  of,  .584 

infianunation  of,  57;!,  575 

lacing-lobe  in.  .584 

Liebernieister's  grooxes  of,  570,  584 

in  malaria,  586 

mesothelioma  of,  589 

necrosis  of,  .586 

nutmeg,   .572 

(edema  of,  57.'} 

pigmental  infiltr.ition  of,  ,585 

poisi  IIS  acting  on.  «.'! 

pres.sure  groo\es  in,  .584 

regeneration  of,  190.  1!!6,  .589 

s;i'   unia  of,  .589 

sii.ipe  of.  variations  in.  570 

syphilis  of,  3a2 


Liver,  syphilis  of,  hepar  lobatum  in,  583 
syphilomas  of,  ,582 
thrombosis  of,  573 
tuberculomas  of,  .382 
tuberculosis  of,  miliary,  .581 
tumors  of,  589 
Mvidity,  (MM) 

I-obar  pneumonia,  4.52,  4,53 
Localized  infection,  145 
Locomotor  ataxia,  500 
Ixtoped   imbilical  cord,  (565 
Ludwig's  angina,  .528 
Lungs,  447 

abnormalities  of,  447 

actinomycosis  of,  465 

adenoma  of,  465 

apneumatosis  of,  449 

aspergillus  of,  465 

atelectasis  of,  449 

brown  induration  of,  448 

carcinoma  of,  465 

carnified,  450 

chondroma  of,  465 

chorio-epilhelioma  of,  466 

cladothrix  of,  465 

cyanotic  induration  of,  448 

disea.se  of,   due   to   disturbance  of 

respiratory  function,  449 
distomum  Westermanii  of,  465 
echinococcus  of,  465 
embolism  in,  449 
emphysema  of,  4.50 
endothelioma  of,  465 
fibroma  of,  465 
fibrosis  of,  interstitial,  465 
glanders  of,  465 
gummas  of,  465 
hemorrhage  into,  448 
hyperemia  of,  447 
hyphomycctes  of,  465 
hypostatic  congestion  of,  447 
infarct  in,  448 
inflammation  of,  4.50 
infrequent  infections  of,  465 
lipoma  of,  465 
lymphosarcoma  of,  465 
(edema  of,  447 
osteoma  of,  465 
sarcoma  of,  465 
streptothrix  of,  465 
strongylus  of,  465 
syphilis  of,  464 
teratoma  of,  465 
tuberculosis  of,  4.59 
tumors  of,  465 
Lupus,  699,  701 

of  vulva,  t)4I 
I-uxation  of  penis,  {i33 
Lymph  cysts,  292 

of  peritoneum,  .568 
nodes,  411 

abnormalities  of,  411 
.tnthnicntic,  412 
atrophy  of,  413 


^^i-*i 


TM\ 


ISDEX 


13 


Lyiiipli  rioilfs,  calcilicMliiiii  "i.   \\.\ 
.liUctH'ialiiiii  III'.   ll:i 

ClillKllisIM  lit,    IIJ 

('iiiliitlii'iioiiia  lit.  II  I 
cMliaiirr  (if  li.arli-lia  ami.  ^7.  !tl 
I)V|icr('tnia  of,  U'J 
infill lal ions  of,  li:! 
itillaiiiiiialioii  of,  11'.' 
iicirosis  of,  li;{ 
irilcina  of,   112 
.svpliilis  of.  U'J 
lliliiiiiltosis  of,  II'J 
tuliiiriilosis  of,  II'J 
tumors  of,  41 1 
\  ariccs  of,  41 '2 
strcaiii,  iM<'la>iasis  and.  217 
l.vniptiaili'iiitis,  412 
I,yirililian(jit'<'l;isis,  2SII.  2M,  Mu,  411 
of  ailrctials,  42:} 
of  skin,  "(Mi 
l-yinpiiantiio-i'iidotliclioiMa,  277,  2N2 
of  |)ia-.iracliiioiil,  -VHi 
of  skin,  7()() 
LynipliauKionia,  2S() 
cavcrnosuni,  2M 
of  inti'stincs,  .ICKI 
of  larynx,  44:i 
of  skin,  7(H) 
LvinphanKiosarcoiiia,  414 
l.ynipli.itic  li'iikcniia,  24(1.  :i(i."),  41  I 
obstnirl'ion,  n'llfnia  from,  iid'.l 
svsU'in,  ;{()l'> 
vcssi'ls,  :!71,  41(1 

abnormalities  of,  410 
inllamiiiatioTi  of,  41 1 
tumors  of,  41 1 
l.ympliatisni,  472 

I.vmpluM    H's  in  iiifiammatioii,  12S,  iiti^J 
Lymplioix  tlii'mia,  240 
Lymphocytosis,  ;!(>4 
I.vmpliojirnic  imcumonia.  4.")t 

tuhcrculosis,  404 
Lvmplioiil  tissue,  ri'tii'iiiratioii  of,  lOli 
l.ymplioma.  2:iS,  210 
l,ymi)liomatoiii   conditions   alTcctiim   the 

spleen,  241 
Lyinphomatosis,  2oN 
Lymphorrhatria,  111 
I,ymphorrh(ea.  2M 
l.ymphosarcoiTia,  240,  111 
of  intestines,  .">()l 
of  luntis,  4(>.') 
of  >!iediastinuni,  472 
of  pericardiimi,  ^JS") 
of  mouth.  o'JC) 
of  thymus,  472 
I.vmpliosarcomatosis,  211.  414 
r.ysis,  llCi,  14't 


M 


M.aeroi  iphaly 
Macrocheilia, 


4S.-) 


:i()7,  411 


.Macrodactviv,  01 

,Macroi;lo,s..'ia.  01,  2M.  :«i7,  411.  .VJ:} 

.\lacropham  s.  ;io;5 

M.idura  foot.  702 

.Mai  lie  C'aderas.  '.Ci 

lie  coil,  0."> 
Malacia,  myeloplaslic,  07'.» 
M. liana,  anOpheles  ?•  •)s(|uilo  and,  !)7 
parasite  of,  '.t7 
types  of.  07 
.Male  sexual  orjians.  (WO 
Malformations,  local,  71 

rect.al,  74 
.MaliuiiancN'.  2l"> 

NlaliciKint  adenoma  of  uterus,  ti.')l 
endocarditis,  H'.Mi 
neopla;  ms,  214 
(Uislule,  7<M) 
dnutrilioii.  .V.t 
atrophy  from,  207 
intn.  ulerine,  as  cau.se  of  disease, 
predis|Misition  and,  110 
Maltase,  iiO 
Mammary  (jland,  000 
aberrant,  (>00 
absence  of,  00<> 
accessory,  <)00 
adenolihrosarcoina  of,  070 
adenohj)olil)roma  of,  t)70 
•ailenoma  of,  i)Ure,  ()70 
adenomalo.si.s  of,  00^ 
adeuomyxo.sarconia  of.  (i70 
anomalies  of.  000 
atrophy  of,  t)t)7 
cancer  "en  cuir:i.s.se 
can  iiioma  of.  ()7() 
chondroma  of.  072 
cystadeiioma  papilliform  of, 
cysts  of.  000,  070  _ 
endothelioma  of.  072 
tibro-adcnonias  of,  000,  (>70 
libroma  of.  072 
libromatosis  of.  Ot')N 
heinorrliatte  into,  000 
liypopiasia  of,  000   _ 
inliammation  of_.  007 
melanoma  of.  t>72 
o.'-teoma  of,  t>72 
peril lieliona  of,  t)72 
sarcoma  of,  072 
secretions  of,  KK} 
syphilis  of,  ()07 
transiilanlalion  "'•_-"" 
luberiulosis  of,  (>(>7 
tumors  of,  OON 
vicarious  menstruation  in,  d 
Marantic  thrombosis  of  dura  mater, 
".Masked"  iron,  27 
".Mast  cells."  i:«,  :50:i 
Mastitis,  007 

chronic  cystic.  070 
phlejjnionosa.  007 
retention.  0(')7 
Mastoiditis,  .'dit 


of,  07(1 


/.v/>a;.v 


fif  (lisi'iisc,  .V.I 


illiforni  <il.  •>"*' 


Mf.i.sK's,  iirKaiiisiii  of,  it.! 

skill  in,  t)!H),  (i'.»7 
Meckel's  (li\erliciiliiiii,  "i '  1 
.NIi'iliMi:  i-left  pMlale,  71 
Mediasliiiiii-..  170 

Mediaslinopeiii'anlili-,  imliirai  ive.  :!n4 
,\le(liastinuiTi.  17(1 

deriiKiiil  cvsls  nf.  171 
iiiflaiiiiiialioii  of.  470 
lyiiipliDsareoina  of   472 
sareoin.a  of.  47'J 
teratomas  of.  471 
limuirs  of,  471 
Medullary  eareiiioina,  2()(i.  '27',i 
of  Miaiiiiiiary  kI.iikI,  I>72 
of  sloinaeli,  .">:{',• 
MeKiieoloii.  .'i44,  "itVi 
Mesalol)lasts,  3.")il 
Megaloeyles,  ;{.")!( 
MeKiistoiiia,  iM> 
Milaniii.  :{4 
Melaiioina,  2s;{ 

of  niairitnary  uland,  (>72 
of  skill,  70t) 
Melanosis,  H24 
Melanotic  piiiinentation,  '.i'2i 
sarcoma  of  choroid,  51;") 
of  liver,  5S*t 
of  vulva,  t)42 
Melena,  :C)4 
Meinhrane,  i:{4 

diplitlierilic,  4;{S 
Meiiilir.'inous  colitis,  iiriS 
enteritis,  ,'>4'.» 
(jastritis,  .53.") 
larynjjitis,  441 
pliarvnaitis,  -i'.is 
Mc'ndel's'hiw,  4S 
M'  'linsies,  cranial  ami 
■iKisinus,  4.*<.S 
icilis,  .*)04 
..iidocele,  I'M 
If   inco-encephalilis,  .")0,") 
li  norrliaina.  3.")4,  ()4t> 

filndid  nf  uterus  and,  242 
Mi'MNtrnation.    vicarious,    in 

liland.  tititi 
Mcseii'liyinatous  tissues,  22<'> 
''li'seiicliyme.  22.") 
ilesaorlitis,  syphilitic,  40S 
lesohlast,  22{ 

Mcsohlaslic  metaplasia,  2!14 
Uixnlidymiis,  tiS 
>lt•^(lthelial  neoplasms,  22."),  22(i 
li'sollielioin.as,  274.  277 
of  liver.  .")S(1 
of  testes,  (V^il 
iesothelium,  22.") 
I'taholie  inloxi,  atioiis,  SO 
iitaholisin,  faulty,  t'out  and,  107 

impaired,  as  u  cause  of  dise.aue,  107 
part  playeil  hy  nucleus  in,  22 
I'taholitci,  l{;i 
'<  laiiiorphosis,  reveinioiiuiy,  2".l'.l 

47 


spinal,  ")01 


m.immavv 


.Metaplia.s<'  of  mitosis.  40 
Nlelaiilusia,  202 

(list  inci ion  of,  from  anaplasia,  20;{ 
epillielial,  204 
of  joints,  ti'.t.") 
me.sohlastic,  204 
o.s.-eous,  20,").  2(!»'> 
.Metaplastic  ossification.  2'Mi 
Metiislases  of  helMKii  tiiiiiors.  220 
liy  lilooil  slre.'iiii,  21N 
in  hones,  ti.V.I 
ill  infection,  H.") 
by  lyiniih  stream.  217 
of  neoplasms,  217 
patency  of,  221 
retrourade,  21!> 
sarcoma  and,  2.")0 
tissue  of  predilection  for,  221) 
hy  transplantation,  21.S 
Mctitstasis,  21.") 

by  apposition,  210 
Metastatic  abscess  of  brain,  4SS 

pneumonia,  4.")2,  4")7 
Metazoa  a.s  cau.ses  of  disease,  ilS 

excretion  of  toxins  by,  !•!> 
Meta/.oan  parasites,  !'.H 
Nlethemot'lohiniiria,  322 
Methvlamin,  110 
Metritis.  t)47,  t)4!»,  <)t)3 
Metrorrhania,  3")4.  (147 

fibroid  of  uI<tus  and,  242 
Microcephaly,  4H") 
Micrococcus  urea',  1)2.") 
Microcytes,  .3.5!t 
Micromolia,  (')7S 

.\licroor(£anisms,  iiltraiiiicro.scopic,  03 
Nlir-rophthaliiiia,  i'M) 
Alicrothelia,  tMMi 
Miliaria,  tiOS 

Miliary  anetirysm,  40S,  4SN 
pncuiiionia,  4.52 
tuberculosis  of  liver,  ."hSl 
'•Milk  siK)ts"  in  i)ericarditis,  3S4 
"Miner's  elbow,"  t)7S 
Mitosis,  ,V.) 

anapha.se  of,  40 
irrcKiilar,  in  cancer  cells,  222 
metapha.se  of,  40 
pr()[)ha,so  of,  30 
telophase  of,  40 
Mitotic  (ell  (livision,  3.S 
Mitral  valve,  double  orifice  of.  .'503 
.Mixe<l  tumors.  210 
.\Iobility  of  kidney,  OOS 
NIodific'ation,  40 

ac(|uired,  43,  44 
Moist  nangrene,  330 
Mole,  fleshy,  212 

liemorrhaKic.  '-!'- 
hydatid,  212 
piumented,  27S,  (')0.5 
pl.acental,  211,  ()t)4 
putrefactive,  212 
of  skin,  70,") 


f 


738 


l\HKX 


MdIwuIc,  liiophoric,  27 
of  .■.■11.  24 
.>i'  |>r.)tfiii.  2t 
M.iUiis.^iiiii  c.jiit.'iu "-I"".  -•"''*•  "*'•' 

lilii'.isiiiii,  247 
M.iiickclxTji's  .icl.TDfis,  4(14 
M.)iiii.^hi)ri:il  twins,  <>2 
Ni<in.)l<it>iiliir  I'irrliosis  of  Iimt,  .JSO 
.\I.>iioini.^l.';ir  liyiilini-  .■.■Un,  i:i2 
Nloii.>.>t>li:il  iwiiiH,  t')2 
Mori.)rflii.li>iii,  ti;{7 
M.diosyiiiiiictri.^al  jiini.cps.  <»S 
Monsters.  .l.)iil)l<>,  t>4 

iil>ic.)p.)liir  fusion  in,  tW,  •>'•' 

pnrasitic,  'ilt 
M.mstriisitics,  (H 
^I.lrl>^ls  cu'riilciis,  .'isti 
Mortjauni,  liv.iati.l  of.  2X'.t 
Mortilication,  ;{2S,  :{4;{,  :i4t> 
.Morula.  22:5 
.Motility  of  kiilncy.  ti"^ 
M.)tor  sy.stcni,  t)7;{ 
Mottlcrki.lncv.  larn.',  (112 
MoiiMs,  '.i2 
.Moiitli,  .522 

abiiornialitii's  of,  .")22 

actin.>inyc.)sis  of,  .")2") 

anemia  of,  't2'-i 

an){i<»"!i  <'f-  •"'-'' 

chan.Te  of,  "»24  ^ 

(■lion.lr.nna  .if,  •")2('> 

epith.'lioma  of,  i>2.") 

filiroina  of,  .")2."),  .")2(> 

mnninas  of,  .")2."> 

liyp.Teniia  .)f,  ")2;{ 

iiiflaniniation  of.  -t-'-i 

leprous  n.xliil.^s  of.  .")2.") 

lip.)iiia  of,  .")2.").  .j2t)  _ 

lytnpho.sarconia  of.  ')2ii 

mucous  pla.pK^s  in,  ")24 

tnyel.ima  of,  )jiant-fpll.'.l,  ")2.") 

myxoma  .if,  ")2.') 

poisons  acting  on,  N2 

syphilis  of,  .V24 

teratoma  of.  .")2.'),  ")2(> 

t  uh.^rculosis  of,  .">2.") 

tumors  nf.  .j2.") 
Mucin,  2.').  :i4 

formation.  ;i(>7 
Mucino(jen.  ^54 
.Nlucoid  (l.'Uen.Tati.in,  :{()(',  •'507 

ilep.>sils.  :j()7 

polyps  in  .r  ■.>pha(jus.  'tM 
Mui'opuruli-ni     iflammati.tn,  i:{4 
Mucous  c.ilit    .  o.W 

cvsts,  2!)() 

mcmbr.an.',  retii-nerali.)i.  of,  lit.) 
transplantation  of,  201 

Iila.pKW,  ')'2\,  701 

surfiicc,  intlatnmation  .)f,  IIW 
Mucous,  bactericidal  iM)\ver  of,  S(> 
.Mulberry  .'alculi.  HIS 
Multilobular  iiv.'r.  .■>7(> 
Multil.HMilar  cvsts  .)f  liver.  .V.M) 


Multili"  ulur  cvsts  of  ovary,  t>.')t» 
Mullipl.'  births,  «4 
neurofibroma,  'M) 
s.'liTosis,  4<tS,  4!»!t,  ."i(H),  ."lOI 
.MummiHcati.m,  XVi,  (Hiu 
.Mimips,  '128 
Munich  l«t'r  hcirt,  336 
Nluscarin,  110 
.Muscles,  ()73 

abnornuil  insertion  of,  »i7:i 
.irigin  of,  ()7iJ 
size  of,  <»73 
absence  of,  073 
actinomycosis  of,  ()7."> 
aiiemiii  <>fi  073 
ani^i.onii  .if,  07*> 
atrophy  .if,  07.") 
.•loii.h  swelling  of,  (i7") 
contt  .1  lions  .if,  4S1 
.•ysticcrcus  of,  t)7.") 
.lefect  of,  (i73 
(leueneration  of.  07.5 
e.'hin.ic.iccus  of.  07.") 
fibrillary  twitchini;  of.  4S4 
tibromii  of,  070_ 
(tlan.lers  .if,  ti7") 
guimiiii  of,  07.5  _ 
hematoma  ii.  (i74 
lietii.irrhane  .if,  074 
hyperemia  of,  ()73_ 
hy[i<"rtrophy  of,  07(i 
infarct  of,  074 
inflammati.m  of,  074 
myxoma  of,  070 
|iara.site.s  I'f,  075 
pete.'hiir  .>.,  074 
reiluplication  .if,  073 
r.'ti.-nerati.in  of,  I'.H),  l'.'0_ 
rhab.l.imyosarc.ima  of,  070 
sarcoma  .if,  070 
spinill.-is,  ()73 
sypliilih  "f.  075 
t'oiULs  of,  4S1 
trichinia-sis  of.  074 
tubercul.isis  <if,  074 
tuiii'  rs  of,  070 

Zenker's  .legenerat ion  <if,  0.0       __ 
.Muscular  atr.iphy.  procrc.s.sive,  4W»,  (><■> 
mechanism  of  respirati.jn,  42it 
system,  poisons  acfing  on,  SI 
Mutation,  .50 
Mvcosis  of  auditory  m.'atu.s,  olS 

funRoides  of  skiti,  700 
Mvootic  nneurvsm,  40S 
Myelitis,  405,  49S,  MM) 
Nlvelocystocele,  494 
Myolocytps,   origin   .if   leukocytes  tnni 

194 
Myelopenotis  leukemia,  238,  365 
.Myelomas,  2.30 

giant -ccllwl,  237 
of  bones,  089 
of  mouth.  525 
multiplex,  237,  239,  420 


IShEX 


7:}n 


Myt'lotims,  multiplex,  ol    Imiif    nuirrou, 
12(1 
of  boiu's,  (iS!) 
Myclonmtoid,  ZiH 
MyeloinutoNis,  '2'.i7,  l'_'(t 
Mycloiiiciiitifiocolc,  4!ll 
Myolojiiiintic  tiiuluciii,  07!) 
Mviaws,  702 
Myocunlilis,  ;iH8 

u(;iit<>,  liHH 

intcrHtitml,  .'{S" 
Myocaniiuin,  3,S"> 

uhnnriniiiilicN  of,  3.S."> 

lUrophy  of,  '.isa 

culcificut  ion  of,  ;{<.U 

cloudy  KwclliiiK  of,  '"IMS 

(k'Rrnoral ion  of,  3M».  .'{!)(' 

dilatation  of,  .VXi 

diMpluccnii'nts  of,  ;{,H,'> 

dupliration  of,  3K.j 

ectopia  of,  ;W5 

Hbrunia  of,  ',HY,i 

fibrosis  ol,  ;JS7,  aiH 

fraKinentation  of,  'Ml 

KUinnia  of,  38X 

hyaline  rlianne  in,  .'Wl 

hypertrophy  of,  liS'i,  ;{!»! 

hy|M)plasia  "of,  38.i 

infiltration  of,  388 

inflammation  of,  388 

lipoma  of,  3S>3 

malnutrition  of,  .■J87 

myxoma  of,  393 

sarcoma  of,  3!)3 

segmentation  of,  3i)l 

syi)hiloma  of,  388 

transposition  of,  385 

ti'berculosis  of,  388 

tumors  of,  3'.»3 
Myofibroma  of  ovary,  (>.V.) 
Mvoma,  241 

of  bladrler,  (>27 

of  Fallopian  tubes,  t)54 

of  intestines,  .")C() 

of  kidney,  ti21 

of  U'sophagus,  .")31 

of  orbit,  .">I7 

of  skin,  7(),") 

of  stomach,  53!) 

of  uterine  ligaments,  H)>2 

of  uttTUs,  241-243,  ti'M 

of  vulva,  642 
Myomalacia,  387 
Myomatosis  with  "'anduhir  inclusion  in 

uterus,  651 
Myopathy,  675 
Myositis,"674 

ossificans,  206,  674  j 

suppurative,  674  ! 

Myotomes,  225 
Myringitis,  518 

Myxochondroma  of  bones,  68i»  ' 

'•lyxiLdeiuH,  liK) 

hypertrophy  and,  189 


Myxa-dema,  thyroid  extract  and 
Myxo-enchondroma,  235 
Myxoli|Kima.  232 
Myxoma,  232 

of  iHjnc  marrow,  12(1 

of  Injnes,  tiS!t 

of  brain,  I'.tl 

of  bronchi,  4  !»'• 

of  bursa',  67'> 

of  lornea,  515 

of  kidney,  (121 

of  larynx,  443 

of  mouth,  525 

of  muscles,  676 

of  myocardium,  3!t3 

of  skin,  705 

of  imibilical  cord,  <>(i5 
Myxomyoma  of  uterus,  650 
Myxosarcoma,  25C 

of  bones,  689 

of  peripheral  nerves,  509 


N.nvi,  705 
blue,  278 
piismented,  7((3 
of  skin,  705 
telaiiKiectatic,  278 
of  vulva,  tm 

Xails,  708 

abnormalities  of,  708 
favus  of,  708 
hemorrhuKcs  of,  708 
inflammation  of,  708 
ingrowing,  708 
leukopathia  of,  708 
ririKworm  of,  708 

Nasal  [Kilyps,  436 

Nasopharynx,  428 

Necrobiosis,  326 

Necrosis,  32().  328 
of  adrenals,  422 
of  bone,  681 
coagulation,  328,  344 
colliquative,  328 
focal,  ,328 

of  individual  cells,  328 
of  liver,  573,  586 
of  lympii  nodes,  413 
of  pancreas,  595,  597 
of  peritoneum,  567 
putrefactive,  328 
of  skin,  7(H).  703 
in  typhoid  fever,  5.50 

Necrotic  cysts,  287,  294 
of  brain,  492 
inflammation,  134 
ulcer  of  intestines,  ."  18 

Needles  in  peritoneum,  ,")66 

Nemathelminthes.  98 

Neoplasia,  207 

Neoplasms,  206 


101 


740 

N(  >|iliisiiirt  of  iiilrciiiilK.  27."),  I-J 
aiiaplit'iiii  ill,  -^■> 
.'iiiciiiiii  from,  2Hl 
of  iirtcricH,  4(»'.t 
iitypiciil,  -H 
uuioiioniou.f,  '-07 
Ix-nittii,  214 
of  bile  «lu.ls,  ■><!•.» 
of  l)l.i.l.lfr,  tV.>7 
blootl  viLsculiir,  ii^ 
of  bone  marrow,  -Mli,  4-11 
of  hones,  tiSS 
of  l)rain,  4'.ll 
of  brfiiHt,  »M>S 
of  hrotifhi.  44(V 
of  bursa',  t'wH 
of  oapillarios,  410 
of  rarotiil  uluml,  '2s:t 
ci'Usof,  ili'strui'tion  (.1    J>>( 
imx'ulatioii  ai.tU  -^7 
radium  and,  ■-X7  _ 
si'lonium  and,  '-K7_ 
tpilurium  aIld,JJ^7 
j-niys  iind,  2S7 
of  choroid,  TdS 
of  conjunctiva,  '.ii> 
of  cord,  .50} 
of  cornea,  ."tl.'i 

dcttcncralivc  changes  in,  222 
distinction  of,  from  cysts,  JN< 
of  doubtful  relationship,  2M 
of  dura  ni:itcr,  ."itW 
of  car,  .520 
embrvonic,  22'> 
endothelial,  220 
epiblaslic,  22.5,  22C. 
of  eve,  .51.5 

of  l'ai.,.iiian  tubes,  (j.>4 
of  trall-bla.ldc  r,  .5(12 

-duct.  r)<»2 
healinu  of.  223 
of  lieart,  'Mi 
livlic,  22.5,  220 
atvpieal,  2.iO 
typical,  22S 
hvi>ol)laslie,  225,24(1 
ii'iflamniatory,  207 
internal  secretion  of,  200 
of  intestines,  ■5(>0 
of  iris,  r)I5 
of  joiiiis,  ''15 
of  kidney,  27;5,  021 
of  larynx,  44:i 
lepidic,  220,  25< 
atypical,  2M 
typieal,  257 
of  liver,  .5S<) 
of  lunKs,  4t)5 
of  lvnii)h  nodes,  414 
of  lymphatic  vessels,  411 
iiiaiiijnant,  214 
,,;■  ;,i,i,„iiiary  ;r!and.  '>•'>> 
of  iiiediasi ilium.  171 
inesenchymatous,l22t) 


IS  1)1-:  X 


Xeoplusms,  inesolhi'lial,  22.5,  220 
metastasi's  of,  215 
mixed,  210 
of  mouth,  .525 
multicenlricjJl'.) 
of  muscles,  070 
of  myocanliuni,  IJICI 
of  nerves,  5t''J 
of  nose,  4:50  .       , , , 

nuclear  cnannes  m.  -'-'- 
of  (isophauus,  .>ll 
of  orbit,  517 
of  ovary,  27.5,  (mO 
of  paiicreiis,  .5(17 
of  iM'lvic  structures,  tm2 
of  iM'iiis,  iVM 
of  iK-ricardium,  ;f>j.5 
of  jM-ritoneum,  507 
of  piu-arachnoicl,  5(M» 
of  placenla.JHH 
of  pleura,  470 
of  prostate,  tWiO 
of  puerperal  uterus,  IM)3 
of  retina,  515 
ret  roRression  of,  223 
of  salivary  (jlands,  52S 
secondary,  215 

of  spinal'  rord,  4(10,  4'.>(S,  4!«>,  .500 

of  siileen,  4\X 

of  stomach,  •53.S 

stroma  in,  221 

of  teeth,  .527 

of  tendons,  t)77 

terminology  of,  207 

of  testis,  275,  030 

theory  of,  2N5 

of  thyroid  itl'V'id,  42;) 

inin.sitional,  220 

of  tunica  vaiiinuhs  testis,  t>i/ 

typical,  214  . 

undilTercntiation  in,  2N> 

uniceiitric.  2 lit 

of  ureters,  024 

of  urethra,  ti2(t 

,  urouenital  ilucis,  2<o 
of  uterine  lifjainenls,  tMJ- 
of  uterus,  t)5() 
of  vanina,  643 
of  vulva,  641 
Neoplastic  fibrosis,  U.> 
Nephritis,  fJ00,,tiOO     , 
cryoscopy  in.  '>0<) 
hemorrhagic,  012        ^ 
interstitial,  acute,  010 

chronic,  60ti,  014-01t> 
parenchymatous,  acute,  001),  Oil 
i  chronic,  612 

'  scarlatinal,  616  _ 

suppurative,  t)17 
Nei)hrolithia.«is,  023 
Nephrolysin,  lt)3 
Nerve-cell  body,  473 

patholottica!  chaiiKCs  in,  4. 


IXDKX 


741 


.NPrve-ri'll,  falmucof    111 

rfKi'Mcnitioii  rif,  lit.s 
NVrvf  tiicclmni.Miii  nI  hear',  .'<77 

tixNiif,  nulolysiN  of,  cliolin  anil,  UNI 
ri-KCMcr.'ttion  of.  1!W 
Ncrvi'H,  tiiDtcir,  '(K'hI  syinptoiiiM  in,  4S2 
ill  I   'ii|ilitMiriM,  221 
IHTiphonil,  'M7 

n-Kcnoriition  of,  after  .ffction,  I'.Kt 
NfTvoiiH  raiiNCH  of  inllaiiitiiutiun,  122 
(liathcHiM,  .").H 

iiirrhaniMiii  of  rt-apiration,  420 
system,  473 

afferent,  474 
aiitonor.'iie,  475 
efferent,  47.") 

foeal  ehaiiKes  in  results  of,  4S2 
neneral  ilistiirl>aiires  of,  47') 
local  I'lianKes  in,  results  of,  482 
|H>isoiis  aclinic  on,  .SO 
pyrexia  un«'    1  ")2 
syinpathcl!  ,    7.'> 
tetanus  tovi,   ami,  1")7 
N'eiirin,  1 1(» 
Neiiriiionia,  247,  24s 
of  stonm<^h,  .Vi'.) 
.\eiirinonmt(»sis,  247,  riOll,  7i>1 
Neuritis,  .t()7 

alcoholic,  M)',  ,")(I,S 
arsenic,  M)S 
l«'a.l,  .")()8 
optic,  .t07,  .")17 
toxic  forms  of,  ,'>()S 
N'eiirobliwtomas,  244 
Neuriicvtoma,  244,  24.'>,  J22 
Xeurofihronias,  multiple,  'Mt 
N'eurotihroniatosis,  2.{() 
Neuroglia,  reiteneratiiin  of,  I!IS 
Neuromas,  244 

of  adrenals,  422 
amputation,  lltK,  24.5,  .'iOfl 
'false."  .■>()!» 
of  optic  nerve,  .517 
Neurone,  20,  473 

connections  between,  113,  11  i 
correlation  of,  474 
uroups  of,  474 
lesions  of,  478 

depressive     manifestations     of, 

484 
irritative  manifestations  of,  484 
upper  motor,  diseases  of,  408 
Neuroparalytic  hynereniia,  338 
Neuropathic  atrophy  of  joints,  694 
of  muscles,  675 
(edema,  370 
Neuroses,  predispasition  toward,  115 
Xi'uroretinitis,  albuminuric,  513 

gravidic,  514 
Xciirotonic  anemia,  3.'?9 

liypeiemia,  338 
Neutrophile  leukocytes,  362 
New  growths,  214 


.N'ko'ih,  '.15 

Nipple,  curcinonin  of,  l  7..' 
Nissl  ImmHcs,  lit,  473 
xM'turnal  enuresis,  tM)5 
NikIc,  aiiriciiloventriciilar,  .377 

sino-auricular,  377 
\(Ml(»se  arterioHclerosis,  402 
Nodule.  138 
.Noma,  .524 

Non-parasitic  intoxications,  7(1,  80 
Non-protein  constituents  of  cell,  31 
.Non-s|M"'ific  immunity,  1.52 
Non-\ii     ular     area,  '  inHummation      of, 

1.34 
Norii,     ii  Iierilance,  51 

y      m,  164 
.Nori.    .(lasts,  .3,59 
Nose,  434 

adenoma  of,  436 

anomalies  of,  434 

carcinoma  of,  436 

catarrh  of,  435 

endothelioma  of,  436 

fibroma  of,  4.'«> 

glanders  of,  436 

hemorrhag*'  "f.  4.34 

hyperemiii      .  434 

infjammali.iii  of,  435 

leprosy  of,  436 

polviis  of,  436 
"saddle-back,"  685 

sarcoma  of,  436 

syphilis  of,  436 

tuberculosis  of,  436 

tumors  of,  436 
Nuck,  Ci.nal  of,  cy.tts  of,  2!)1 
Nuclear  changes  in  neoplasms.  222 

fluid.  18 
Nuclc-UM',  lOH 
Nucleic  acid, : 
Nuck  In  25,  2'. 

bjses,  -.5 

'  ■nviition  of  purin  buses  from,  107 
Nuc'i  inic  acid.  27 
Nuv'W    I  ;:     18 

NlK:le.^^     18 

alterations  in,  23 
chemisi ly  of,  27 
chromidia  of,  22 
composition  of,  27 

cytoplasm  and,  interaction  between, 
20,  21 
interrelation  bctveen,  21 
liisintegration  of,  23 
dominance  of,  20,  21 
granules  of,  22 
histology  of,  18 
importance  of,  20 
karyolysis  and  karyorrliexis,  23 
"inaske<l"  iron  in,  27 
'1  inetabolLsm,  22 
,.ho.^phoru»  in,  27 
proteins  of,  27 
relation  to  cell,  21 


11  Ii 


fer 


742 


IXDEX 


Xucleu.s  relation  to  inctabolisin,  22 
Nunipriciil  hyprrpliisiti,  1S(J 
Nutritional  hypertrophy,  ISS 


Oat-shapk  eellcil  siirconia,  2.')4 
Obesity,  lOS 
( (hlluatorv  anaerobes,  ,S4 
(>l)literati()n  of  nail  ihiet,  ")01 
Ob.strucfion  to  air  in  nvpiration,  431 

of  ureters,  (i23 
Obstruetive  cirriiosis  of  Hver,  ."it 

eon.stipation,  .">42 

jaundiee,  10."),  ;i2:{ 

telansieetasis,  2~.S 
Obturator  iiernia,  M'y'J 
Oe<'hisi()ii  of  arteries,  340 

of  bronelii,  440 

of  (esopliaftus,  .")2!( 
Oeeuit  heinorrhatje  of  intestines,  ."(47 
Oeiu'onosis  of  joi   Is.  <i!t4 
Odontoma,  2.'U),  .•)27 
(Mdeiiia,  300,  0!tO 

agonal,  447 

aiiKioneurotie,  370 

eon;iestive,  ,{Oit 

of  conjunctiva,  ."»()!• 

of  Kail-l)ladder,  .")<»1 
duet,  .")<tl 

of  (jlottis,  441 

inHaniinatorv,  370 

interstitial,  300 

of  labia,  041 

of  Hver,  ")73 

of  luntis,  447 

of  lymph  nodes,  412 

from  lymphatic  obstruction.  30!l 

tieiiropathic,  370 

of  pharvtix,  437 

of  pi;i,  2!m 

of  pia-araclinoid.  .")0t 

of  placcnt:i,  t>04 

pulmotiary,  307 

of  scrotum.  040 

of  ski'i,  OOO 

of  tonsils,  4:{7 

toxic,  370 

types  of.  30(» 

of  vulva,  041 
(Ks  )ph;ij;itis,  ."(31 
(Ksophairus.  .VJ!) 

carcinoma  of,  .")31 

iliphtheri.a  of,  531 

diverticula  of,  ."(30 

duplication  of,  ")2!( 

epithelioma  of,  .")31 

hemorrhage  into,  ."(31 

infljimmatioti  <(f.  .531 

leuk((plakia  of,  ."(31 

lip((inas  of.  ."(31 

malf((rm.'itioiis  of.  .")2!l 

mucoid  poly|>.-  In,  ."i.'il 


(KsophaRiis,  iTiyonias  ((f,  ."(31 
occlusion  of,  ."(2!( 
I)erforatioii  of,  .").30 
rupture  of,  ,")30 
stenosis  of,  .")2!> 
.syphilis  <(f,  ."(31 
tuberculosis  of,  ,"(31 
Old  age,  ."(.") 
Oleiii,  .33 
OliKemia,  3.3.') 
<  )li)iolivdrainiii((,  00."( 
Oliuuria,  002 
Onychia,  70,S 
( )nyelioKryphosis,  70S 
;)ocyfe,  primary,  40 
Oiipliorilis,  ((."(."( 
Opacity  of  lens,  .")()!»,  ."d" 
Ophthalmia,  )!onorrh(e;ii.  01 

sympathetic,  ")12 
Opsonic  index,  Itid 
Op.sonins,  lOS 

phagocytosis  and,  KiS 
Optic  disk,  (tipped,  ,"(lli 
nerve,  ")17 
neuritis,  .")07,  .")I7 
Orbit,  .")17 

absces.s  of,  517 
angioma  of,  .")17 
carcinoma  ((f,  "(17 
eelluliti.s  of,  517 
hjcroma  of,  517 
inflammation  of,  517 
myoma  of,  517 
osteoma  of,  517 
sarcoma  of,  517 
teratoma  of,  517 
Orchitis,  .".2S,  03.S 
( )r(janisiii,  normal  defences  of,  ,S0 
Orgaiis,  defects  in,  70 
Osmosis,  32 

hyperisotonic  solutions  and,  33 
hypi.sotonic  solutions  and,  33 
Osseous  metaplasia,  2(15,  200 
Ossification,  metaplastic,  231) 
OssifviiiK  ecchondroses  of  bones,  0,S!( 
Osteitis,  6.S0 

eon<iensin({,  0S2 
def((rinans,  41!»,  t(S2,  ()S5,  O.SO 
rarefyiiifr,  0S2 
Osteo-arthritis  of  joints,  001 
Osteochondritis.  0S4 
( )steochondrosarconia,  2.50 
Osteo-et\cliondronia,  234 
Osteogenesis  imperfecta,  079 
O.steoid  sarcoma,  250 
<  )steoma,  235 
of  brain,  491 
of  bronchi,  440 
of  conjunctiva.  515 
of  dura  mater,  503 
of  ear,  ,521 
of  lunps,  405 
of  m.iminarv  (jlaml.  '>72 
of  orbit,  517 


IXDEX 


743 


Osteoma  of  pleura.  470 

of  skin,  70") 
Osteoiiiiilacia,  4 lit,  t>S.'> 
O.steoniiitoid,  2;{(i 
Osteomyelitis,  GSO,  G,si 

chronie,  (182 

fibrosa,  (iSti 

tufxTculosis  ami,  tlS.'{ 
Osteoporosis  of  hones,  (iK2,  (iS") 

<  )ste()psathyrosis,  67!t 
Osttv)sarc()ma,  2.")t),  CSO 
Otitis  media,  .jlX  ,")20 

acute,  oIO 
hemorrhagic,  'AH 
suppurative,  .jiit 
sclerosing,  ,")2() 
Otosclerosis,  .VJO 
"Ovarian  dermoid, "  200 
teratoma,  200 

<  )vario(!ele,  042 
Ovary,  t),")4 

abnormalities  of,  ^t,"> 

a<'cessory,  0."),') 

adenofibronia  of,  (mO 

atrophy  of,  O.'iO 

carcinoma  of,  OoO 

cystadenoma  of,  (i.")(i 

cystom.a  of,  0,jO 

(•ysts  of,  (i.")f) 

deReneration  of,  cystic,  tJoti 

diseases  relat(>d  to  secretion  of.  1(>2 

elastoid  chaiiRes  in,  (•")() 

endothelioma  of,  (i.10,  VM) 

fibroma  of,  C.")0 

hyaline  changes  in,  ((."lO 

hypoplasia  of,  0.').") 

inflammation  of,  0.").5 

myofibroma  of,  <).")0 

perithelioma  of,  tioO 

psammocarcinoma  of.  (\'i>.) 
regeneration  of.  100 
sjircoma  of,  (1.50 
.secretions  of,  102 
syphilis  of,  O")") 
teratoma  of,  000 
fr.insplantation  of,  2(K) 
I  iherculosis  of,  0.");") 
tumors  of,  275,  ().J0 

connective  tissue,  0.")0 
Overgrowth,  1,S6.    .SV.  also  Hypertrophy, 
conipen.satorv,  IS.S 
irritative,  l.S.H 
simulatinl,  l.Sit 
vicarious,  ISX 
Overnutrition,  fatty  infiltration  ilue  to 

;«« 

Overstrain,  111 

distinction  of.  from  overstress,  1 12 

muscular  fatigue  and.  1 13 
Overstress,  112 

a  cause  of  disea.se.  112 
Overwork,  atrophy  from,  207 
Oviil.a  N'abothi.  2<'«).  (i4.S 
Ovum,  "blighted,"  .")K 


Ovum.  niaturati(m  of.  40 

polar  bodies  of,  41) 
Oxidiise,  107 

<^>xidation,  diminished,  .UKi 
Ozen.H,  4;i.i 


I'.*<'J1VI)KI(MAT()CEI,K,  .')00 

P.acliy<|ermia,  312,  411 

laryngis  verrucosa,  442 
I'achymeningitis,  .^02 
I'aget's  di.seii.se  of  bone.  O.Sli 

of  nipple.  072 
Pain.  179 

collapse  and,  17.S 
distribution  of,  segiricntal,  1.S2 
localization  of,  I,s.'{,  1,S4 
referred,  IHI 
shock  and,  17.S 
I'almitin,  Xi 
Pal.sies,  birth.  01 
I'ancreas,  .VXi 

abnormalities  of.  .'><.H 

absence  of,  ,")04 

a<'ini  of,  accessory,  .")!I4 

adenomas  of,  ."i!(7 

amyloid  of,  .")!)7 

carcinoma  of,  .'i<)7 

cystadenoma  of,  .")07 

cysts  of,  .■.<».S 

duplication  of,  .504 

fat  necrosis  of,  oOo.  ")07 

fatty  degeneration  of,  .")07 

infiltration  of.  ."i07 
glycosuria  and.  .")04 
granulomas  of.  .50.5 
hemorrhage  of,  .")0.i 
hyperemia  of,  .")0.5 
hypoplasia  of,  .504 
inflamrnation  of,  .50,5 
internal  secretion  of,  IO;i 
passive  congestion  of.  50.5 
regeneration  of.  100 
sarcoma  of,  .50S 
-self-digestion  of.  .500 
tuberculosis  of,  .50,5 
tumors  of.  .507 
I'ancreatic  i'oncremcnts,  ,jl.5 
Pancreatitis,  centrilobular,  .505 
chroi.i<-,  ,505 
hemorrhagic,  acute.  505 
perilobular.  .505 
purulent,  .595 
sporadic,  595 
I'annus,  511 
Panophthahnilis,  512 
Panoslitis,  tJ8<),  (WI 
P.apillary  cystom.a  i>f  ovary,  (i5.S 
Papilloma,  257 

of  bladder,  201,  Ii27 
bla.stomatous,  2(i() 
of  conjunctiva,  515 


l^ll 


It' 


w 


ii  i 

111 


f:l 


7(!1 


1711 


744 

Papilloma  of  coriira,  .")l"i 
of  Kallopiati  lulic-i.  Cm  I 

of  illlCslilH'-'.  .")<>•) 

iiitracvstic,  '2t)l 

of  iriitalivf  orisi".  -•">" 

of  laiviix,  4li{ 

soft,  2(i() 

of  un'tcrs,  1)24 
Papular  svpliiliiU'  of  skin 
Paralvsis;47!) 

liiilhar,  4>.MI 

hysterical,  4S:{ 

lesions  of  neiiroiu's  aiK 
Parametritis,  (147,  (Mil 
Parametrium.  (Mil 
I'arapliimosis,  t);i() 
I'arap'asm,  lU 

I'araplejlia,  coiiKeiiital  spastir,  4!!S 
I'arasitcs  in  bladder,  ti'Jti 

"cancer,"  I'.l 

of  malaria.  !>7 

tnelazoan,  as  causes  of  disease 

of  muscles,  (17.") 

of  pleura'.  47(' 

"sarcoma, '   12."il 

of  skin,  7i'2 

of  lueteis,  1)24 

of  uterus,  t)4'.( 
I'arasilie  causes  of  disc; 

cysts.  2SS.  2i).'i 

of  ixuK's.  ('('.k; 

of  t)iain.  4".  12 

of  liver,  .")'.(() 

of  perilondim, 
embolus,  ■ii)'.i 
intoxications,  7!> 
monsters,  t)i( 
"  Paraspecific"  (pialitie.- 


l.XDEX 


•IS 


SI 


.".lis 


inlieritanee  ;ind,    PeptoiK 


Patent  ductus  Molalli.  :{SIJ 

Pallio)jenie  bacteria,  s."i 

I'alholojjical  slates,  iidierited,  ati 

Pcliculosis,  702 

I'dlajira,  .")1U 

I'elvic  mass,  inflammatory,  lilU 

peritonitis,  productive,  (i()2 

structures,  (Mil 
Pemplii(£us,  Oils 
Penis   i).U) 

absent,  (>;}(1 

anomalit'.s  of,  liifll 

(■.•in'inoma  of,  ti-W 

chancroid  of.  O-il 

cy.sts  of,  (>l{3 

dermatitis  of,  <»'{<• 

(hmble,  (>:il) 

elephantiasis  of,  0;i2 

enilotlielioma  of.  (i^W 

(ibroma  of,  iY.i'.i 

fracture  of,  (i.'W 

hyi)opl;'stic,  ti^iO 

intiammation  of,  iVM) 

injuries  of,  OIW 

keratosis  <if,  032 

lipoma  of,  OM 

luxation  of  0;{:{ 

I)himo.se<l.  (mO 

sarcoma  of,  ii'-i'.i 

soft  chaiirii-  of,  Oiil 
sore,  li.iJ 

sypliili,s  of,  0;iO 

tulierculot-is  of,  0;V2 

tumors  of,  lUii 

venereal  wart  of,  0152 
IVptic  ulcer  of  intestines.  .")4S 
of  stomach,  .")l{(> 


Paiasyphilitic  lesions.  .")7 
Paraluberculous  lesions.  .")7 
Parathyroids,  42t> 

adenom.'i  of,  420 

diseases  related  to.  101 

liypi'rplasia  of.  420 

se<'retion  of.  11)1 
Parenchymatous  tioilre.  <lifTuse.  424 

keratitis,  ditTusc.  .'il  I 

nephritis,  01)0,  Oil.  012 
Parent.il  inlicritatn'c.  4S 
I'aresthesia.  47(1.  4S2 
I'arinauil's  conjunctivitis.  .")11 
Paronychia,  70S 
Parotitis,  epidemic,  .")2S 
Parovarian  cysts  of  uterine  li(iaments,  002 
Paroxysmal  hemoiilobinuria,  :i22 
I'.irliculate  inheritance,  4S 
I'arturieiil  causes  of  disease.  .")S 

disease,  ."."i 
Parturition,  pathological  state-i  .iciiuired 

durint-'.  01 
Passive  conireslioii.  ii.'iS 

iimnunily.  I'i4 
Patent  ductus  arteriosus.  :<S0 


Perforation  of  bronchi,  440 

of  intestine.  .'J.'iS 

of  o'sophasus.  .>iO 

in  otitis  medi;i.  .")Mt 

of  stomach.  .V17 

in  typhoid  fever.  ">.>{ 

of  uterus,  ()40 
I'crforative  appendicitis,  ')'>' 
Pernicious  anemia.  :iOO 
Periarteritis,  chronic.  400 

of  luntj,  40.") 
PeribroiKhitis.  40.") 
Pericanalicular   libro-adenoin.i 

mary  gland.  070 
I'ericarditis,  3S2 

a<lhesi()ns  in.  3S3 

I  hronic,  '^Ki 

"milk  spots"  in,  :{S4 

purulent,  :\S.i 

recurrent,  3S;{ 

serofibrinotis,  3S2,  ;!s;{ 

serous,  3S;5 

syphiliti<-,  3S4 
Pericar<lium,  ;5.S0 

abniiriiialilics  of,  iJSl 

adhereni,  ;{s:{ 


of   nii 


ISDEX 


745 


I'cricanlium,  iipciniii  of,  '.iS2 
iilropliy  of,  .  ^l 
<'y,stict'rcu.s  of,  ;>S") 
(!cliino('(M'cus  of,  '.i:->' 
iiiHaniiiK  tioii  of,  ;{>12 
lyinphosan^oin.'i  of,  ;{S.') 
new  n;ro\\  i  lis  of,  ;W.") 
petechial  .spots  on,  •'isl 
IVricliolwyslitis,  punileiii.  .")!t2 
rcrichoiulritis,  .")IS 

I'ericlionilriiiin,  transplantation  of,  2(11 
Perilobular  pancreatitis,  .V.I") 
I'erilvinpliadunitis,  412 
I'eriiiietri-.'s.  ()47,  ti4<t,  (if.l.  <M)2 
Periinetriiiii    Ml 
I'eriiieal  hernia,  .")()!) 
I'cTinephrie  abscess,  (117 
I'eriorehitis,  (>;}" 

Periosteal  reneiieration  of  bone.  ]'Xi 
Periostitis,  (iS(» 

albuinino.sa,  (M2 
of  ear,  .")1.S 
ossificans,  ()S2 
suppurative,  tiSl 
P<'riosteuin,  traiis|)lantation  of.  2ill 
Peripheral  nerves,  5(17 

defeneration  of,  .V'S 
fibromatosis  of,  .")()!( 
gliomas  of,  ."iO!t 
infective  Kratmlomas  of,  ,")()s 
inflammation  of,  .')()7 
lead  poisoning  and,  oOs 
leprosy  of,  .")(IS 
lipomas  of,  .5()!( 
myxo.sarcomas  of,  ;"()!> 
neuroma  of,  oOil 
regeneration  of,  lO.S 
rhabdomyoma  of,  .'(Ht 
.syj)hilis  of,  .")().S 
tuberculosis  of,  otJ.S 
Perithelioma,  2S2 

of  manmiary  gland,  072 
of  ovary,  ().")!1 
of  salivary  glands.  .Vi.S 
Perilotieum,  otil 

abnormal  contents  in,  otMi 
abnormalities  of,  ")ti2 
actinomycosis  of.  ,")(>(> 
anemia  of,  ")t)2 
angioma  of.  ot)7 
bile  iti,  ")(>() 
cystadenoma  of,  i"ti7 
cysts  of,  ■")t)7 
embolism  of,  odlJ 
endothelioma  of.  •'J<>7 
fibroma  of,  .")()7 
gallstones  in,  .")()(> 
hemorrhages  of.  .")('>2 
hyperemia  of,  "i()2 
inflammation  of.  .ViU 
lipochondroma  of,  .")(i7 
lipoma  of,  .")()7 

necrn^clN:  (if,  !\iu 

iiecdlcs  in.  ."itKi 


Peritoneum,  i)a.ssive  congestion  of,  .")<i2 

pigmentation  of.  .">(i7 

sarcoma  of,  .")(>7 

sponges  in.  'Mi 

syphilis  of,  .5()0 

teratoma  of,  .")tJ7 

thrombosis  of,  .5(1;! 

tuberculosis  of,  ."id,") 
sicca  of,  ,")t)0 

tumors  of,  o(J7 

worms  in,  500 
Peritonitis,  .")03 

chronic,  iili'i 

hemorrhagic,  .">0:{ 

hyalo.serositis  in,  oOo 

local  circutnscribed,  ^AXi 
diffuse,  .'503 

productive  i)elvic,  002 

purulent,  .")0;{ 

serofibrinous,  503 

serous,  503 

imivcrsal,  .503 
I'eriton.sillar  ab.seess,  437 
Pernicious  anemia.  300 
Persistent  cloaca,  74 

truncus  arteriosus,  3,S0 
Petechia-,  3.54,  074 
I'feiffer's  reaction.  Kit) 
Phagedenic  ulcers,  700 
Phagocytosis,  bacteria  and,  124 

opsoiiin.s  and,  lOS 
Pharyngitis,  437 

acute  catarrhal.  437 

atrophic,  chronic,  43'( 

chronic,  43it 

gramilar,  43!) 

membranous,  43S 

phlegmonous,  4.3!S 
Pharynx,  42S,  43t) 

abnormalities  of,  437 

hyperemia  of,  437 

inflanunation  of,  437 

anlema  of,  437 
Phimosis,  030 
Plilebectasia  Kirvnge.i.  441 
Phlebecta.sis,  410 
Phlebitis,  410 
Phleboliths,  315,  351 

of  ))elvic  veins,  001 

of  pr<istatic  veins,  03,1 

ill  uterine  ligaments,  001 
PIdebo.sclerosis,  410 
Phlegmon  of  skin,  700 
Phlcjimonous  cystitis,  (i25 

enteritis,  .540 
ga.stritis,  535 
inHammatioii,  134 
laryngitis,  442 
pharyngitis,  43S 
Phlyctentilar  keratitis.  512 
Phosphatic  calculi.  31S 
Phosphatides.  27 
Pliiivpliiiriis  if.  iiiu-lcus.  27 
Phthisis.  402 


Bf  'i 


74G 


IXDEX 


Phthisis  btilbi,  513 

"libroi.l,"  41)2,  463 

pneuinoii'c,  acute,  403 
Physical  causes  of  disease,  75,  77 
Physiological  albuminuria,  6(13 

hypertrophy,  187 

inertia,  36 
Phytotoxii  *,  154 
Pia-arachnoid,  5()4 

a  ^emia  of,  504 

cavernonias  of,  500 

cholesteatomas  of,  50(5 

endotheliomas  of,  506 

tibroniiis  of,  50(5 

gummas  of,  506 

hemangio-endothelioiiias  of,  500 

Hemorrhage  of,  504 

hyperemia  of,  504 

inclusion  dermoids  of,  500 

inflammation  of,  504 

lipomas  of,  500 

lymphangio-endotheliomas  of,  500 

lymphangiomas  of,  500 

(edema  of,  29!),  504 

passive  congestion  of,  504 

sarcomas  of,  506 

syphilis  of,  506 

tuberculosis  of,  505 

tumors  of,  506 
Pictou  cattle  di&euse,  5S1 
"  Pigeon-breast, "  687 
Pigments,  321 

derive*!  from  hemoglobin,  321 

embolus,  353 

in  kidney,  620 

in  liver,  585 
Pigmentation,  321 

endogenous,  321 

exogenous,  324 

melanotic,  324 

urobilin,  324 
i'igmented  moles,  278,  005,  703 
Piles.  .547 
Pineal  gland,  493 
Pituitary  body,  492 

acromegaly  and,  493 
diseases  related  to,  101 
secretions  of,  101 
Placenta,  064 

anemia  of,  t>M 

angioma  of,  004 

calcification  of,  OOi 

cell  embolus,  352 

chorio-ppithelioma  malignum  of,  {')G-t 

cysts  of,  ()04 

degeneration  of,  664 

disciise  of  effect  of,  upon  f(rtus,  60 

entrance  of  bacteria  through,  90 

fibroma  of,  6t)4 

tibromyonia  of,  664 

fleshy  mole  of.  211,604 

hemorrhage  of,  (KVt 

hydatidifnnn  mole,  211,  604 

hyperemia  of,  004 


Placenta,  infarct  of,  664 

inflammation  of,  (>64 

(edema  of,  6(J4 
!  '/nevia,  664 

i         succenti    .ata,  (j(>4 
I  syphilis  of,  6(j,  (M54 

tuberculosis  of,  6(54 
Plain  muscle,  regeneration  of,  IOC) 
I  Plasma,  blood,  357 
i  cells,  132,  3f)3 

changes  in,  357 
Plasmorrhexis,  359 
i  Plasnioschisis,  359 
Plastic  cyclitis,  512 

pleurisy,  407 
Platelets,  blood,  360 
Platyhelminthes,  98 
,  Plethora,  335 
i  hydremi(!,  335 

Pleura,  466 

angioma  of,  470 

chondroma  of,  470 

contents  in,  -tOO 

endothelioma  of,  470 

fibroma  of,  470 

hemorrhage  into,  466 

hyperemia  of,  466 

inftanmiation  of,  407 

leprosy  of,  470 

lipoma  of,  470 

osteoma  of,  470 

parasites  of,  470 

sarcoma  of,  470 

syphilis  of,  470 

tuberculosis  of,  470 

tumors  of,  470 
Pleural  cavities,  433 

effusion,  434 
'  Pleuricentiic  blastoma,  219 
'  Pleurisy,  407 
1  "dry,"  468 

!         exudative,  467 
I  fibrinous,  468 

hemorrhagic,  4()9 

hyaloserositis  in,  409 

plastic,  407 
'         productive,  467,  469 

purulent.    Sec  Empyema. 

serofibrinous,  468 
i  with  effusion,  4(58 

Pleuritis.    See  Pleurisy 
Pleurogenetic  pneinnonia,  457 
Pleuiopneumonia  of  cattle,  organism 

93 
Pneumonia,  450 

aiirogenic,  451 

apical,  455 

aspiration,  45(5 

brown  induration  in,  458 

(central,  455 

chronic,  457 

congestion  in,  452 
'  (rrecpiiig,  455 

embolic,  457 


jBtm^v  -11!^^ 


INDEX 


747 


Pneumonia,  engorgement  in,  452 
hematogenic,  451 
hepatization  in,  gray,  454 
hypostatic,  452,  457 
indurative,  secondary,  457 
inhalation,  456 
lobar,  452,  453 
lobular,  acute,  455 
lymphogenic,  451 
metastatic,  452,  457 
miliary,  452 
pleurogenetic,  457 
resolution  in,  454 
septic,  452 
splenization  in,  4.')<) 
terminal,  452 
tuberculous,  401 
"unresolved,"  457 
"white,"  465 
Pneumonic  phthisis,  acute,  4t).{ 
Pneumonitis.    See  Pneuuionia. 
Pneumonokoniosis,  325,  457,  45h 
Pneumothorax,  434,  467 
Poikilocytes,  359 
Poikilothtrmic  animals,  148 
Poison,  76 

acting  on  blood  corpuscles,  81 
on  digestive  .system,  82 
on  heart,  82 
on  intestine,  82 
on  kidneys,  84 
on  liver,  83 
on  mouth,  ,•52 
on  muscular  system,  81 
on  nervous  system,  80 
on  organs  of  circulation,  82 
on  stomach,  82 
on  vessels,  82 
endogenous,  79 
exogenous,  79 
Polar  bodies,  46 
dichotomy,  66 
hypogenesis,  70,  71 
Poliomyelitis,  495,  499 
Polyblast,  133,  191 
Polychromatophilia,  359 
Polvcythemiu,  358 
Polydactyly,  70 

Polydactylism,  inheritance  and,  57 
Polyhydramnios,  665 
Polymastia,  70,  666 
Polymorphonuclear  cells,  128 

leukocytes,  362 
Polymyositis,  674 
Polynuclear  cells,  128 

leukocytes,  362 
Polyorchidism,  637 
Polyp,  aural,  520 
I'olypeptids,  26 

I'olypi,  destructive  placental,  212 
Polyps  of  nose,  436 
I  polythelia,  666 
i'lilyuria,  601 
Porencephaly,  486,  492,  498 


Portal  cirrhosis  of  liv(!r,  575 
Post-fibrinous  fibrosis,  143 
Posthitis,  630 

.  Post-natal  ucquLi-ement  of  disease,  74 
I         disca.-":,  55 
!  Post-uterine  hematoma,  661 
Preeipi  jns,  161 
;  Precipitoids,  162 
;  Predilection,    tissue    of,    in    metastasis. 

220 
I  Predisposition,  1 '  '> 
I         age  and,  ll(j 

habit  of  life  and,  1 16 
inherited,  115 
malnutrition  and,  116 
previous  infection  and,  116 
sex  and,  1 16 
Premature  labor,  causes  of,  60 
Preputial  concrements,  315 
Pressure,  atmospheric,  as  cause  of  disease, 

diverticula  of  u'sopnagus,  5.i(» 

grooves  of  liver,  584 
"Prezymogens"  of  cell,  23 
Priaiiism,  630 
Processus  pyramidalis,  423 
Procidentia  of  uterus,  645 
Proctitis,  548 
Productive  pelvic  peritonitis,  662 

pleurisy,  467,  469 
Progressive  cataract,  515 

muscular  atrophy,  499,  675 

inheritance,  51 

tissue  changes,  185 
Prolapse  of  uterus,  645 
Pinliferants,  cell,  201 
Proliferative  fibrosis,  142 
Prophase  of  mitosis,  39 
Prostate,  633 

aberrant,  f  "3 

absence  of,  633 

amyloid  bodies  of,  321,  633 

anomalies  of,  633 

atropl.y  of,  634 

carcmoma  of,  636 

concret'">s  in,  633 

corpora  amylacia,  633 

cysts  of,  6.33 

degeneration  of,  634 

foreign  bodies  in,  633 

hyperemia  of,  633 

hypertrophy  of,  634 

multiple  caseous  nodules  of,  033 

phleboliths  in,  «»33 

sarcoma  of,  dSQ 

tuberculosis  of,  633 

tumors  of,  636 

unilateral  hypoplastic,  033 
Prostatic  calculi,  321,  633 

sand,  321,  633 
Prostatitis,  633 
Protagon,  27 
Proteins,  24 

combined,  25 


ifi 


k 


HI 


74S 


i.\i)i':x 


f.f 


[ii. 
ri- 


IVntcins,  conslitulion  of,  24 
fiizyiiu's  of  biictcriii,  Kl 
free,  2") 

tni)li'('ul<"  of,  21 
of  iiiirlcus,  27 
Protozoa  as  cause  of  (liscjisc,  !W 

(I'.'vciopiiiftil  of  toxins  in,  !W 
"I'roud  flcsii,"  I2(i 
Psaiiiinocaicinotiia  of  ovary,  0.')9 
Psaiuinoiiia,  2,S2 
bodies,  .')(»;{ 
I'seudoeliylous  ascites.  ;{"() 
i'seiulolienuapliroilisinus  iiiusciilinils,  74 
i'setuioliyiM^rtropliy,  isti 
I'seudoinelaiiosis,  1522 
I'seudoniyxoitiM  peritoii'      •''•">M 
I'soriasis,  ti'.Ht 
I'terytjiuiii,  .")11 
I'loiiiaines  as  cause  of  disease,  I  If) 

development  of,  bacteria  anil,  11(1 
Puerperal  uterus,  (i()2 
l»ulinonary  (edema,  ;i(>7 
Pulp  tissues,  primitive,  220 
Pulpitis,  .")2() 
Pulse,  veiions.  372 
Puncture,  70 
Puriii  ba.ses,  27,  lOS 

bodies,  107 
I'urulent  arthritis,  0'.»2 
bronciiitis,  444 
choroiditis,  ,">!;< 
cvclitis,  .")12 

encephalitis.     Sir  i'rain,  abscess  of. 
inHammation,  i;54 
paiicre:itius,  .")'.l.") 
pericanlitis,  '.iS'.i 
pericholecystitis,  .")!t2 
periorchitis,  0.'17 
peritonitis,  ;")();{ 
pleinisy.    .See  Empyema. 
teno.synovitis,  070 
Purpura,  3.5.5,  OiMi 
Pus,  125 

••lau<lable,"  i;W 
Pustule,  nialisnant,  700 
I'ulrefaction  i"  infarction,  345 
Putrefactive  bactc -ia,  S.5 

necrosis,  32S 
Putrid  bronchitis,  445 
Pyelitis,  017,  02:5 
cvstica,  024 
Pveloiiephrilis,  000,  017,  024 

tuberculous,  OI!l,  ti24 
Pylephlebetic  abscess.  575 
I'yloric  stenosis,  533 
Pyometra.  t>40 
I'yonephrosis.  til 7 
calculous,  01 S 
tulx'rculous,  t)H'  _ 
Pyopneumothorax,  407 
Pvorrluea  alveolaris,  301.  .527 
P\iw;i!piii\,  <>53.  054 
Pyrexia,  147,  1 4'.t 
causes  of,  151 


(Ji  iNsv,  437 


1{ai'Hi.sciiisis,  4it3 
"Huchitic  rosary,"  0S7 
llucliitis,  087 
Kar'ial  characters,  47 
diathesis,  ,5N 
•nheritance,  47 
inherited  preilisiK)sition,  115 
Radiant  energy  as  cause  of  iii.sea.se,  77 
iiadiinn  a.s  cau.se  of  di.sease,  'S 

cells  of  tumors  and,  2S7 
"Railway  spine,"  495 
Ramila,  ii'JO,  525 
Rarefaction  of  bone.s,  0.S2 
Rarefying  osteitis,  082 
Raynauil's  disease,  320,  339 
Receptors,  158,  10.5 

orders  of,  Khrlich's,  173 
Recessive  properties,  4.S 
Rectocele,  042 
Rectovaginal  fistula,  043 
Recurrent  fever,  149 

pericarditis,  3S3 

splenitis,  417 
I{ed  atrophy,  acute,  of  liver,  -574 

bl<M)d  corpuscles.    .Sec  I'Irythrocyt) 

infarct,  344 

of  1'   er,  572 

kidney.  »arne,  62 

softeniiifi  of  brain,  487 

thrombus,  347,  3.50 
Reducible  hernia,  .5()8 
i{((luplication  of  nuisdes,  073 
Itef erred  injury,  122 

pains,  181 
Regeneration,  189 

of  axone,  -.78 

of  blood-vascular  tis.su' ,  194 

of  bone,  192 

of  cartilage,  192 

of  connective  tissue,  191 

of  endothelium,  190 

of  epithelivun,  194 

of  fatty  tissue,  191 

of  glands,  190 

of  hair,  195 

of  hematoblasts,  194 

of  kidney,  191,  190 

of  leukocytes,  194 

of  liver,  190,  190 

of  lymphoid  tissue,  193 

of   mother  cells  of  red    blood    <■• 
puscles,  194 

of  mucous  membrane,  195 

of  muscles,  1<K),  190 

of  nerve  cells,  198 
tissue,  HIS 

of  nerves,  478 


l.ShEX 


7VJ 


Regeneration  of  iioiirojiliii,  I'.IS 

of  ovary,  UMj 

of  [miuTca.x,  1!M> 

ot  jwripliiTuI  iicrvoN,  lilS 

of  HobaciHuis  glands,  IKo 

of  spleen,  ISMi 

of  sweat  glands,  lit") 

of  testis,  1!M> 

of  thynml,  liHi 
Regions,  special,  defects  in,  70 
Iteiapse,  146 
{{(■lapsing  fever,  OS 
Relative  innnunily,  1")2 
Remittent  fever.  149 

•nfection,  14b 
Repair,  122 
"Replacement  dropisy."  ;{71 

fibrosis,  142 
Reproductive  system,  (530 
Reserve  force,  .'{7 
Resistance,  lowered,  oO 
Resolution,  complete,  in  infarction,  ;{4") 

of  lung,  4'A 
Respiration,  Cheyne-Slokes,  431 

disturbances  of,  42'J 
asphyxia,  430 
coughing,  4:iO 
dyspncra,  430 
sneezing,  42!) 

ipochanism  of,  420 
Resi)irafory  system,  427 

tract,  entrance  of  bacteria  through, 
90 
physical    hindrance    in,    to    en- 
trance of  bacteria,  87 
Retention  cysts,  2S7,  288 
of  liver,  590 
of  pancreas,  .598 
of  skin,  707 

mastitis,  667 

of  urine,  (50.5 
Reticulated  cnchondronia,  234 
Retina,  .510 

anemia  of,  olO 

choked  disk  in,  510 

degeneration  of,  .514 

embolism  in,  510 

glioma  of,  515 

hemorrhages  in,  510 

hy-ijeremia  of,  510 

inflammation  of,  513 

thrombosis  in,  510 

tumors  of,  515 
Itetinal  glioma,  246 
Uetinitis,  513 

hemorrhagic,  514 

pigmentosa,  514 
IJetroHexion  of  uterus,  645 
IJetrogrtide  metasta.sis.  219 
lictrogression  of  neoplasms,  223 
Hi'trogressive  inheritance,  51 
!!i'!niph:iryngn:il  abscess,   I3H 
Uetro-uterine  abscess,  661 
Ueversibility  of  enzyme  action,  30 


1.54,  \: 


253,  254 
537 


Reversion,  .50 
Reversionary  jitrophy,  203 

inheritance,  .50,  51 

metamorphosis,  299 
Rhabdomyoma,  243 

of  perii)heral  nerves,  509 
Rhabdomyo.sarcoma,  257,  676 
Rheumatic  fever,  692 
Rheumatism,  692,  693 
Rhinitis,  435 
Rhinoliths,  315 
Rhinoscleroma  of  larynx,  443 
Rice  bodies,  677,  (>94 
Ricin,  imniunitv  against,  1.54.  155 
Rickets,  687 

"Riders'  bone,"  20t),  236 
"Riding"  embolus,  351 
Rigor  mortis,  331,  t>73 
Ring-worm,  702,  708 
Robin,  inmnmity  again. 
Rodent  ulcer,  264,  707 
Itosarv,  rachitic,  (>87 
Roseola,  697 
Round-celled  sarcoma, 

ulcer  of  stomach,  .536, 

worms,  98 
Rubor.  125 
Rupia  of  skin,  701 
Rupture  of  heart,  391 

of  heart  valves,  399 

of  lymphat  ic  vessels,  4 1 1 

of  (i'so|)hagus,  .530 

of  urethra,  <)29 

of  uterus,  646 
"  Rus-sel's  bodies, "  267,  312 


SArcri.AH  aneurysm.  298,  407 

bronchiectasis,  446 
Sacral  teratoma,  congenilal,  ()5 
"Saddle-back"  ro.se,  68.", 
"Sago"  spleen,  308,  41S 
Salivarv  concrements,  .315 
cvsts,  29t) 
glands,  528 

cylindrcmuis  of,  .528 
endotheliomas  of,  .528 
;  infiammatiiin  of,  528 

I  peritheliomas  of,  528 

I  tubcrculf>sis  of,  528 

tumors  of,  .528 
'  Salpingitis,  653 
Salts,  simple,  of  cell,  .32 
Salvar.san,  spirochetes  and,  98 
i  Sand,  prost.ntic,  321,  633 
Sap,  cell,  19 
Sapremia.  145 
Sapremic  intoxication,  145 
Saprophyfi    '    ^teria,  85 

intoxications,  79 
Sarcoblitsts,  244,  299 
Sarcodiniu!,  93 


:»() 


l.\l)KX 


SiircDiMa.  '2'.i7.  2.">(l 

iif  aiiri'iials,  yj'.i 

of  l)lii(l<lcr.  tiL'7 

of  hiiiic  in.iirow.  12(1 

of  holies,  tiXK 

of  lirain,  (<)'_> 

of  liroiiclii,  I  to 

of  hiirsi',  ()7.S 

of  coiijuiicliva.  'il.'i 

of  dura  iiiattT,  "idl 

of  car,  .VJl 

of  (jiill-hladcItT,  .VC 

of  nall-.liicl.  .V.fi 

(jiant-cclli'il,  2:{7 

iiiirriiii'ili.-ilc,  2.')2 

of  iiilcsiinc.-i,  ■)()! 

of  iris,  T)!.") 

of  joillls,  tilt,') 

of  kidney.  -.'lO,  (HM 

of  larynx,  lit 

of  livi'r,  .".sil 

of  luiins,  Ki.j 

of  iiiaiiiiiiary  filalid,  ()72 

of  iiicdiastiiiiini,  172 

of  inilsclcs,  ()7() 

of  iiiyocariiiuin,  .'!'.»:{ 

of  nose,  4:>(') 

oat-sliapc  I'clli'd,  2.") I 

of  orhil,  .")17 

osteoid,  2.')(i,  ()S!t 

of  o\  ary,  (')")!• 

of  pancreas.  .V.IS 

"parasites,"  2.')l 

of  penis,  tili:{ 

of  peritoneum,  "itw 

of  pia-araclinoid,  .")(KJ 

of  pleura,  470 

of  prostate,  (>.'{•> 

lounii-ccllpd,  2.')li,  2.')l 

of  skin,  7(H) 

spindle-celled,  2.")2,  2.">.j 

of  spleen,  US 

of  stomach,  iSM) 

of  tendons,  (>77 

of  testes,  0;{!» 

of  ureters.  (524 

of  urethra,  (t29 

of  uterine  li(£anients,  ()(>2 

of  uterus,  (i.")2 

of  vajiinu,  (143 
f^arcomatosis  of  skin,  71K) 
Scahii's,  702 
Scar,  12(> 

Scarlatinal  nephritis,  (lit) 
Scarlet  f<'Ver,  orttanism  of,  'Xi 

skin  in,  (')i)7 
Schizomycetes.    ■SVf  liacteria. 
Sciatic  hernia,  .">0!) 
Scirrhous  carcinoma,  2(')(>.  27o 

of  mammary  ttland,  072 
of  stomach,  5;}!> 
Sclerema,  7(14,  70.") 
Scleroderma,  704 
Scleni'dema,  704 


SclerosiiiK  otitis  media,  .V20 
ScliTosis,  4!I0 

of  hones,  t)S2 
comhined,  suhacute,  .">01 
lateral,  amvotropliic,  4(t!) 

family' type  of,  4it<.) 
MiinckeherK's,  4((4 
imiltiple,  4',t.S,  4!»0,  ^(H),  r)01 
in  spinal  cord,  4!Mt 
Scrofuloderma,  701 
Scrotal  hernia,  oO'.) 
hydrocele,  2!>1 
Scrotum,  KM 

carcinoma  of,  040 
(■lei)hantiasis  of,  ()4(( 
hemorrhaKc  "f.  MO 
(I'deina  of,  040 
Scurvy,  infantile,  OSS 
Sehaceous  cyst  of  ( ar,  ")21 
of  skin,  707 
(tlaiids,  regeneration  of,  IH.J 
Sehorrlura,  707 
Secretin,  10;{ 
Secretion.s,  internal,  as  causes  of  discii 

1(N) 
Secretory  cysts,  2SS 

Kranules,  22 
Section,  a  cuu.se  of  di.sea.se,  70 
Self-ditjestion  of  ])ancrea.s,  ')'.)r> 
Semilunar  valves,  accessory,  Hita 

fenestration  of,  'A'Xi 
Senile  atrophy,  297 
.Sensorv    and    motor    neurones,    di.sea 
"alTect  iiifs,  .")(K) 
neurones,  disea.ses  atTectiiiR,  r)(K) 
Septa,  iini)erfect,  of  heart,  ;',S0 
Septic  infection  of  umbilical  cord,  00' 

pneumonia.  4r)2 
Se(Hiestration  cysts,  2!W 
Se(|uestrum  of  hone,  tiXO 
Serofibrinous  arthritis,  tiitl 
inflammation,  134 
jM'ricarditis,  ;W2,  liSH 
l)eritonitis,  'iKi 
pleuri.sy,  40S 
Seropurulent  inflammation,  1IJ4 
Serous  arthritis,  Odl 

atrophy,  29S.  :}(«>,  41!) 
cavities,  accumulation  in,  ,'507 
leptomeninpitis,  .")04 
membrane,  transi)laiitatioii  of,  2( 
pericardit  is,  :5S;{ 
l)eritonitis,  .503 
Serpiginous  ulcer  of  cornea,  512 
Serum  albtimiii,  2.5 
■•death,"  170 
globulin,  2.5 
I  inunune,  1(>4 

inactivated,  104 
"sickness,"  117,  170 
Sessile  hydatid,  2S<1 
Su.Kual  orean.s,  i-.ialc,  030 

fenudo,  040 
Shock,  17S 


LSDKX 


751 


jnt'8,    ilisea.-'cs 


Siiilolillis,  .V.»S 

"Siaiiicw  twiii.t, "  (is 

Siclc-cliiiiii  tliciirv  of  iiiiiiiuiiity,   I.")7   ItH) 

Sidcrosi.s,  l{2."i,  t.V.I 

Silicosis,  A'J.'t 

Sirio-auriciiliir  iiodc,  ;{"" 

Sinus  i)f  Imiiic,  (iso 

SirctiDiiirlus,  71 

Skaliil,  (•(iiisli|iiili<)ii  artil,  1 1 1 

Skin.  <>il."> 

alinorrnaliMcs  of,  i><,)5 

absrcss  I  if,  7(M> 

acne  of,  7<H( 

artinoniycosis  of,  7012 

ailiposis  dolorosa  of,  7(l."> 

anasarca  of,  (>!»(> 

anemia  of,  i)!(.") 

aliKioni.'i  of,  7()ti 

atrophy  of,  7().'{ 

l)lasloni\rosis  of,  70- 

hurninii  of,  r>!)7 

callus  of,  7();i 

I'aticcr  "en  cuirassc"  of,  707 

carbunilc  of,  700 

c.'ircinoina  of,  700 

cavcrnonia  of,  70"i 

cellulitis  of,  7(HI 

chancre  of,  701 

cliiKoe  in,  70'{ 

chroniatoplioronia  of,  70<) 

coniciloncs  of,  707 

corn  of,  70l{ 

cyanosis  <>(,  OiHi 

cysts  of,  707 

dcnnaloniycosis  of,  702 

dermoid  of,  707 

ec/,em;i  of,  tiilH 

ch'pliaiitiasis  of,  701 

entrance  of  hacleria  lhroU({h,  ilO 

epithelioma  of.  700 

erysipelas  of,  7tH> 

erythema  of.  t)!t7 

favus  of,  7(:2 

fihr.ima  of,  70."> 

freckles  of,  7();{ 

freezing  of,  tilts 

furuncle  of,  700 

gangrene  of,  700 

({landers  of,  702 

(traftinti,  2(K» 

tjranuloinas  of,  702 

Kuinea-worm  in,  70;} 

(tummas  of,  701 

hairiness  of.  W)'i 

liardenind  of.  704 

hemorrhage  of,  lillti 

herfies  of.  (i'tS 

hyperemia  of,  titMi 

ill     etigo  of,  tilHI 

intlammation  of.  tilMi 

intertriRo  of,  (i!Kt 

ko!()i<l  of.  70.") 

lepra  of.  702 

leukoderma  of.  703 


Skin,  lichen  of,  till!) 

linea'  allticantes  of,  70;{ 

li|Hiinato«iiN  of,  70.') 

lividily  of.  ()<H> 

hipus  of,  701 

erythcmatosu.s  of,  ti'.M* 

iyiiiphaniiiecta.sis  of,  70(i 

lymphaiiKio-cndothelioma  of,  7(M> 

lymphanKioma  of,  70<) 

iiutliKuant  pustule  of,  70(1 

melanoinu  of,  7(Hi 

miliaria  of.  ()<)S 

moles  of,  70.5 

molliiscimi  <-on(a)ciosinn  of,  7().'{ 

mucou.s  |>la(|ues  of,  701 

mycosis  fun^oides  of,  702 

inyiusis  of,  7(M) 

myoma  of,  70.5 

myxoma  of,  70") 

na-vi  of,  70") 

necrosis  of,  700,  7((U 

neiirinoniatosix  of,  70.") 

o'denia  of,  (i'.Hi 
osteoma  of,  70.5 

papular  syphilide  of,  701 

parasites  of,  702 

pediculosis  of,  702 

pemphiKUs  of,  (iOH 
phlegmon  of,  7(K) 
pigmentation  of,  70;{ 
psoriasis  of,  01)9 
I)urpura  of,  (ilKj 
ringworm  of,  702 
rodent  ulcer  of,  7(,'7 
roseola  of,  ()1)7 
riipia  of,  701 
sarcoma  of,  7(M) 
sarcomatosis  of,  7(Mi 
scabies  of,  702 
scrofuloderma  of,  701 
"strawberry  mark"  of,  705 
.syphilis  of,  701 
ihickeninK  of,  704 
tinea  of,  702 
tuberculosis  of,  701 
tumors  of,  70.5 
ulcers  of,  7(M) 
urticaria  of,  (ilt7 
variola  of.  (iltl( 
verruca-  of,  704 
vitiligo  of,  703 
warts  of,  7(t;5,  704 
xanlhela.sina  of,  70.'{ 
xantiioma  of,  70") 
Snee/.inu,  420 
"Snuffles, "  4;}() 
Soaps,  Xi 
Soft  chancre  of  penis,  681 

.sore  of  penis,  ():{2 
Softening  of  brain,  4S7 
Somatic  cell,  44 
S)riics,  ,52.3 

Sore,  soft,  of  penis,  032 
Spasm,  4S0,  483 


IXDKX 


S|i:i.-tir  |)Mr:i|ili'Ki:i.  riiliKi'liit.'il.    I'.•^ 
Spci'ilir  iiilii'iili 'I  |)li'ili>|i(i>iliiili,   11." 
S|M'ClIill  l:ij>  ;i»  1  :iM.-r  iil  i|i>fii>i',  7>» 
S|HTiri;tlir  ciiril.  tilO 

v.iricdci'lr  (if,  liKl 
iliHiiiiiliiatiiiii  III',  till) 
lillM'rriilii!*i>  iif,  tiKI 
S|M'riri;ilipcclc  of  IcnIcs,  (>:{!( 
S|>i'riii,'ttcicvli's,  4."> 
SiiiTiiialiiui'iiiiii".  ••"'■  "• 
S|M'riiiiil(i/.ii:i.  iiialiiialiiiii  ol,  l"i 
SpluKcliis,  MHi 
S|iliiiiK<iinvi'liii,  -7 
Spina  liilii'la,  7'.'.  4.s:).  \'X\ 
(MTulta.  J'.M 
vi'lili(-^a,  (iSo 
Spinal  c'oni,  \'Xi 

aliiKiriiialilii's  iif,   !!•;> 
.iiu'iiiia  III'.  VX> 
aiHinialii'^  "1.  I'-'-' 
I'unnrsliiin  "I,  l''"> 
I'orpiira  .iinylarca  in,   I'.Mi 
(li'KoiuTaliiiii  of. 
uliimiHS  of.  .'itU 
(jlaiiilliiiiias    of. 

I!»'.l 
UHrnnias  of.  I'.Mi.  .VHI 
liitiiorrliaKi'  into,  Iil." 
infection  of,  tiMi 
inllainniatioii  of,  ttl,') 
scli'io-'is  in.  4'.Mi 
tranina  of.  4ftt> 
ttihcrrulosisof.  tiMi.  ."ilK) 
tiiinois  of,   I'M),  4',tS,  41t! 
nicninuc.i.  .'rfU 
."<pini-,  "railway,"  4'.t"i 
Spinillt'-ri'Ucil  sarciiina,  "i.'i'J 
Spirilla,  Si 
Spirillosis,  (l.s 

Spirillum  cliolrra'.  irinlliplii-     on  of.  (Ml 
Spirorhi'l.i      palliila.        Sa       ,'rcponoiiia 

p.illiiluin. 
Spirorlicti's.  its 
Splalirhiioptosis.  41.''i 
S;,lifii.  41,") 

almornialitii's  uf,  ll.'i 
aiccsMi: y,  41.") 
artiiyiniyrosis  of,  41S 
anemia  of,  41  o 
atrophv  of,  4l!S 
•liaron,"  ;iOS,  41S 
li.ieteria  in,  SN 
rani  lonia  of,  41(1 
eonue.slion  of,  41") 
ryaiiotie  iniluration  of,  4111 
ili'tjeiierations  of,  41.S 
embolisni  of.  411) 
glanders  of,  41S 
liemorrliane  of,  4H) 
hyperemia  of,  41  "i 
hyperplasia  of.  4 IN 
infiltrations  of.  4lx 
inflammation  of,  417 
leprosy  of.  4 IK 


»!»»■).  lit; 
infeetive,     I'.tS, 

ttMi 


')(MI 


.Spleen,  Ivmpliomatoiil   eotiilitions  all 
iiitf, --Ml 
retteneralion  of,  I'.t'i 
"sano, "  :«t.s,  lis 
sareoma  of,  4  Is 
svpliilis  of,  4 IS 
thriimhiisis  of,  llti 
tilbernilosis  of,   IIS 
tumors  of,  4IS 
waxy,  :«»S 
Splenic  anemia,  '2i\ 
Splenitis,  117 
Spleiiization  of  lunc.  4.")<'i 
Splenome(jaly,  ernlotlielial,  241 

hemolytic,  'ill,  .')7ft 
Spohilylitis  ileformans.  liltU 
■SpontamiHls  variation,  .")(( 
.S|Mir;iilie  emliryoma,  '2(M» 
infection,  14:{ 
pancreatitis,  .")!>.') 
teratoma,  '.'tHt 
Sporozoa,  iM) 

life-cycles  in,  !•() 
spore  formation  in,  (Ml 
transmission  of,  ',(7 

Siiuamous-celliil  carcin a,  2ti!l 

of  niainniary  ^lanil,  t)7°J 
of  skin,  7IM) 
of  stomach,  ."):{'.• 
of  vulva,  M'2 
epithelial  cvsts,  'J'.f-' 
Stalkeil  hyilatiil,  -'Sit 
Staphvlococcus    pvojrenes, 

ami",  l-Jl 
•Stasis  of  hlooil,  XW 
Status  lyniphaticus,  411,  472 
Steapsin,  ■i'i 
Stearin,  ;{.'{ 
Steatolilhs,  'MS 
Sleatopyny,  2:{:{ 

Stenosis,     conijeiiital     pulmonary, 
atresia,  ;iS(') 
of  heart  valves.  ;{!t7 
of  intestines,  .")44 
of  (esoph.iBU-.  •''2'.t 
pyloric,  o^W 
of  ureters.  ()2:, 
of  uterus.  t)44.  t)4.') 
Slerilitv  of  I)1imm1,  >S 

of  healthy  tissue,  ss 
Sternal  fissure,  72 
Sthenic  fever,  1")() 
Stilll)irtli,  causes  of,  11(1 
Stimuli,  iileoijenous,  4S2 
•'Stipplintj"  of  erythrocytes,  :i."i!t 
"Stitch-hole,"  abscess.  Sit 
St()kes-.\ilams  symlrome,  ;{7!l 
Stonuich,  ");5I{ 

abnormalities  of,  .").'i:i 
iibsonce  of,  "):{;{ 
actinomycosis  of,  ."):{() 
ailenocareinoma  of,  "liSlt 
ailenoma  of,  .JiJlt 
anemia  of,  .>i.5 


intlainini 


iililiiiii"  alTi'cl- 


ISDEX 


rw 


.  211 


la,  2l')'.t 
iil,t)7i 


',    intlaiiiMiatiiin 
172 

iliiKiiiai'v.     with 


,  ;57it 
5 

r> 


Sliitiiai'li,  (•alran'<m~  ll('|M>^ll■^  in,  ."hill 

carcitioina  ol,  ">i'» 

I'lnlioliMiii  aiiil,  'hit 

<'|iilli)'li<iiiia  of,  .'ht'.l 

croHinii-  cif,  lii'iM(ii'rliaL;ir,  .VU 

tibroiiia  of,  .">.{!• 

({laiiili  r*  cf,  .'i.{ti 

hfriiorrliaKi-M  iif,  ■V{.'< 

h<iiii'KlaM.-<.  .'>.'{.'{ 

Iiyix'i'i'iiiia  of,  ."ill.'S 

intiainiiiatioii  of,  .'i.'(.'> 

lipoiiia  of,  '>•<<,) 

niyoiiia  of,  .W.t 

iii'iiriiioiiiH  of,  .Vi'.t 

poi.soii.s  arliiiK  on,  S'2 

.sarcoma  of,  .VIO 

svpliilis  of.  •'>■(•> 

lliroinl)osifi  and,  .">.'{4 

lubfrciilosiw  of,  .");{<) 

lunior.s  of,  it'AS 

illciT  of,  it'M 
Stomal  it  is,  •I'SA,  .T24 

aplitlioiis,  .")2t 

ItunKrciious,  ">24 

suppurative,  .VJt 

ulcerative,  .">21 
StraiiKulaliou  of  intestines  ."1.") 
■'.Strawberry  mark"  of  skin,  7'!.") 

ton(iue,  .")2U 
Streplotlirix  of  lunijs,  4(i."> 
Strialiil  muscle,  retietieralion  of,  1!I7 
Slri<'lure  of  urelhni,  t)2S 
Stridor,  42'.t 

Stroma  in  neoplasms,  221 
Stronjjylus  of  Iuiiks,  M\ii 
Struma  vasculosa,  I2."> 
Subinfection,  147,  Iti2 
Siil)lu?;ation  of  joints,  llitl 
Submucous  liemorrliac'  of  stomaeli,   'M 

myoma  of  uterus,  r>.">l> 
-Subnormal  cell  activity,  ;i7 
Subserous  mvoma  of  uterus,  li.'iO 
Siil)sultus  tendimun.  4S0 
Sunuillalions,  :j"i.") 
-^unburn,  skin  in,  7(i;> 
Sunstroke,  7S,  I")2 
Siip<'rf(et:.ti()n,  l>2 
>llppur:lti^•e  arthritis,  li'.M 

cholecystitis.  .")iH 

hepalilis,  .')74 

keratitis,  ."il2 

leplomenin(jitis,  ."lO.") 

myositis,  1)71 

lieplu'ilis,  1)17 

otitis  media,  .")!!• 

periostitis,  liSl 

splenitis,  417 

stomatitis,  '124 
Surgical"  kidney,  Iil7 
^'wra,  9.") 

^  isccpiibilily,  11.5 
■.ve,ii  irlands.  reueueration  of,  I'.l.') 
-uellmtj,  cloudy,   I2;{,  Ml 
\Mipathetic  hypertrophy,  ISO 

48 


Sympiillietic  nervous  svhi em,  I'.'i 

ophthalmia,  .*>t2 
.■^ympus  apus,  71 
.Synapse,  I  lit,  474 
.Synco|M',  177 
Sviievlial  carcinoma  of  puerperal  uterus 

'  IHk") 
Sviidai'lviv,  71 
.Synechia.  ;<.s;t,  .■>12 
.Synorchidism,  i\'.i~ 
.sVphilis,  !>K 

of  adrenals.  422 

of  arteries,  4(HI 

of  bladder,  (>2I> 

of  bone,  l).S4 

of  brain,  4S!t 

of  conjunctiva,  .'>1 1 

of  cornea.  .")12 

of  dura  mater,  .")0:f 

of  ear,  .".18 

of  Fallopian  lubes,  l).")4 

of  fielus,  IK).") 

of  intesline-,  .")">.') 

of  iris,  .")12 

of  joints,  W.y.i 

of  kidney,  I)  10 

of  liviT,  .")82 

of  lungs,  41)4 

of  lymph  nodes,  412 

of  manmiary  (jlaiid.  111)7 

of  month.  .")24 

of  muscles,  07,') 

of  nose,  4;{ll 

of  (esoi)huKiis.  ."):n 

of  ovary,  11.")") 

of  p<'iiis.  I>:{0 

of  peripheral  nerves,  .")I)S 

of  peritoneum,  'M\ 

of  pia-ara<'hnoiil.  i")IKl 

of  placenta,  im,  0114 

of  pleure,  470 

of  skin,  701 

of  spleen,  418 

of  stomai'h,  .i3ti 

of  tendon  shealhs,  1177 

of  testes.  liUS,  Ki'.i 

of  ihvnnis,  472 

of  tonsils,  440 

of  tiniica  vagifalis  testis,  1137 

of  umbilical  coni,  liH.") 

of  urethra,  1120 

of  uteru.s,  1)40 

of  vulva,  1141 

\Va.ssermann  reaction  in,  1117,  Ills 
(Syphilitic  arterio.sderosis,  403 

cirrhosis  of  liver,  581 

liirvngitis,  443 

.nesoarteritis,  408 

|)ericardilis.  3.S4 
Svphiloma  of  brain,  480 

of  liver,  .J82 

of  myocardiun;,  38S 
SyriiiKoniyeloceie,  202,  40.") 
Svstole  of  heart.  37.T 


7:>\ 


ISDKX 


I-  i 


■\\A»>  i|cii>,ili>.  '.(HI 
•rii'li\.:iii|i;i.  :i;»' 

I'MMiiii  rrlilliiMnc-.n-,  '.l<.l._-_".l.> 

TMil.ir  111'  liTlh.  :>l"i,  .V-'T 
'r;iltlHlill|t.   ii-t 

•r.fiii,  .v.'ii 

liiiii's  (pf,  .VJ(> 
cvsis  i)f.  "r.'s 
(IclVil^  I  if.  •■>--., 
lliilcliiiiM'ii  -■  '''■  ■''-•' 
ihllaiiiiiiuliiin  "f,  jjti,  .'i^T 
liirl.'ir  n!'.  :(!.■>.  .")J7 
trail.-"  '        ,'iim  iif.  201 
llllliol"    •  .  '>-' 

'rrliiiiMlifi'laM-.  .-TS 
..f  kiilii.'V.f.Jl 

•I'riliiriuiii.  •■•■lis  of  nir >  aiul.  '.S/ 

'I'llHiiliaM'  <it  inilo^i^.  '"  ,  ,      , 

■|Vlnl"ialuiv.  a<la|)lali-ii  ot  liuiiiaii  t....!, 
to.  77  ^_ 

as  cause  of  iliscMM'.  77 
coiislalii-y      of,      ill      uallii-Mooilnl 
aliiiiials,  llN 
'ri-ii^liiiili>.  t'>7t'> 
■rciiiloii  slii'atlis.  t>7t'> 

calrurcoiis  cli'|)o>its  in.  In  i 
"(laiittllon"  of^t'>77 
liVL'foiiia  of.  1)77 
iiidainiiialioii  of.  Ii7(> 
li|)oina  of.  1177 
•lice  lioilirs"  ill.  t'>77 
s.-irroiiiM  of.  t'>77 
svjiliilis  of,  ti77 
IMi)(irlllo>i>  of,  (177 
I iiiiiois  of,  t'>77 
'riiiiloiis,  t)7i> 

iiitlaiiiiiiatioii  of,  l>7(> 
-  iiroin.i  ol,  t(77 
tumors  of,  t'>77 
'rciiilova(iiiiitis.  tyi 
'I'liiosviiovilis,  t>7l'> 
■[•••lata,  3>7 
'|"cratol>la-t.iiiia-.  -Mil 

of  l^illll.■,v.  (I'-'l 
'r»'ratoni'liotl>  lila>tollia-,  211.  -'-■• 
'rciatoids,  •>'••_ 
'rcratoiii;i.  '-'(•7 

ronpMiital  -a.-rai.  t).i.  ^.i^    -<«• 

rvslii-, -.'It'.' 

o'f  Kciiil:.!  iilaii(l>,  -'<«• 

of  lllll(.'>.    l'''"> 

of  iii('(tia>liiiuiii.  471 

of  moiitli.  'V-'p.  •''-'' 

of  orliit,  .'117 

„f,,var.v.  -'Il'.l,  f.liO_ 

of  iiciitoiKiiin,  .">t>7 

sDora.lic,  -'(Mt 

of  t.'sti-.  -'(f.t 

of  iircti'is,  (VJt 

of  I-     lii.f  li^aii  iMt.-.  •■'••- 


'rrratoiiialoiis  vy^"  of  unnis.  ti.VJ 
rcriniiial  iiiftilioii.  lil,  I  17 
l(iikocv;oMs,  :{tU 
|iiii'iliiioiiia.  t.VJ 
IC^iis,  i>;i7 

aliiioriiialiiii's  of,  (i:;7 
alropliy  of.  ti;{".| 
ramiioiiia  of,  t'fci'' 
rliori(M'liilli<lioliia  of.  tiill' 
cysts  of.  iV.i\> 
il\>lo|iia  of,  I'fcl7 

hviicrplasia  in,  •>:('.» 

liV|Mrtro|ili>  of,  nmipt'iisator.v 

li\  |io|ilasia  of,  <>;t7 

iiilVclivc  Kranuloiiias  of.  ^V^>> 

iiillaiiitiiatioii  of,  ihiS 

iiicsotliclioiiia  of,  <'•!"•• 

ii'tjriicratioii  of,  \'M\ 

sarcoma  of,  tiit'.t 

secretions  of,  HVJ 

•(iicrmatocclc  of,  (i;>'.t 

svphilis  of,  v,:is.  c.:;'.! 

,■  teratoma  of,  'JO".' 

tiitierciilosis  of,  fiH.s 
tumors  of,  •_'7.'.,  <'':4".i 
Tctaiiie  contractions  ol  muscle,   ISI 
'I'd anus  to\iii,  I."i7 
I'elanv,  101,  I'.'O 
'I'lielitis,  f.ti7 
'riicrinoiieliesis,  1  t7 

'I'lii'oinhiii,  Hit) 
'riii-omhoaiitjeitis  ol.literaiis,  UMl 

rinoml)oncn,  ;5U'i 
I'liroinliokinase,  :!lli 
'riiroinl)o|ililel>itis,  ;i.')l.  410 
'riiromliosis,  lilt) 
of  arteries.  400 
lilooil  plalelets  ill.  .'17 
ill  liraiii.  |n7^4SS 
causes  of    :i47 
cere!.,,il,  41IS 
of  ilura  inaler.  .'lOl 
forms  of,  ',V\S 
liemolvsis  mil,  ''.i^ 
of  kiiliiey,  (MHt 
of  liver,  .'')7:{ 
of  iympli  iioiles,    U'J 
of  peritoiieiini.  ."iti:') 
results  of.  jl.-)0 
ill  f.iina.  ."jlO 
of  spleen.  41t) 
stomach  ami.  'M 
of  veins.  \W 
'i'liromliiis.  Ii4t>.  ;!47  _ 
absorption  of,  ^foO 
arterial.  :{4'.> 
ball,  ;i4>i 
capillarv,  il.'iO 
I'ar.liac.  MS 
nlolmlar.  :W 
livaline.  ;<47 
!ii.el:'.t<-<l.  :r'I 
ort'^mization  of.  .i'A) 
led,  acute.  o-'iO 


ti:i<l 


IM)FX 


l,U} 


Tl.roiiilniM,  ri-'l.  inixfl.  :tlT 
Milli'iiinit  of.  't'>l 

'I'linisli,  .V.'t 

••'riirii^li-hrra.-t"  lii>;irt,  :i!HI 
'riiyinii*.  i''. 


.f,  »:■_' 

Mtrii|iliy  of.  1"'- 
liv|M'r|>l:i>iii  of.  •' 


lowirriiina 


f.  »T 


Ih 


Iviiipl 

xyliliilix  "f.  •"'- 
lillM'iculosis  of.  i''2 
,ri>i<l  rvsis,  2".M 
('\tr:irl,   rrciini->iii   aiiil 


tOI 


IIIV 


\(i'ili'-iia  ami,  1(11 


Klaiitl.  CM 


aliiiiirinr.lilifs  of.  l'j:{ 
iiliM'ii'M'  of,  ^^2^ 
ncci-ssory,  V2'-i 


ili'tiocarriiioMia  o 


f,   1-J 


■  ll'Ilolll 


l.f,  fj 


itropliy  of,  4JI 


cilraii mis  < 


lc|>osits  of.   I'Jt 


cuniiioina,  Narroiii 
cotitjfslioti  of.  421 
cvsts  of.  421 


f.  421 


(li'dcncralloii  ol 
liyiMTplasia  of.  421 
|iyj)oplasia  of,  121 
iiiflaiMtiiatioii  of,  124 
f.  \'M\ 


rcijcncralioii  ol 
transplant  at  ion  of,  2(K( 


tumors  ol 


f,  42.-I 


l£"itrc, 
ri'.'ictii 


2<tl 
III,  (listurhanrc  of,  10(1 


tuniors  of  larynx,  44:{ 
'riiyroldccloiiiy,  101 
riivrolinijiial  cysts,  2.S!> 


Itil'OK 


I  Lodics,  lit,  47;{ 


Tini-a,  702 


rircinata,  i 


(12 


sycosis,  I 
lipiisiiraiis 


(12 


702 
olor,  702 
I'll  cniliolus,  :)."i2 
>s,  l.S.'>,  1M> 


c'lianu( 

(li'vclopincnt  of,  22:{ 
.■n.lotlK'lial,  22t> 
<'iilran<-i'  of  badcria  to,  S(> 
.•pil)laslic,  22.1,  22(1 
lii-aliln  ,  stcrilitv  of.  .S,S 
hvlic,  22."),  22ti 
hypoblast ic,  22.'),  22t> 
ic'piilic. 


nii'sot 


rlivniatoiis 
hclial.  22.-). 


22C. 


f  priHlilcclion,  220 
22(» 


pr< 
pulp,  priniitivi 


Tor-nail,  iiujrowinK,  70S 


I'oi.i  ' 


contractions  ol 


f  inusclc,  4S1 


)ii)ju('.  defects  of.  .■)23 
ccoirraphical.  .">24 
stiawherrv.  :)2;4 

tic.  r)22,  rv>:i 


Toiisilljir  concrcinci 


:ii: 


'ronsilliijs.  chroiiii'  '    Hinilar,   110 
ioiisils.  IHtl 

aliiioriiialitii's  ol,  1;17 
vudalitis  of.  l;{7 


aiiiyK' 
fauces  of.  l.lCi 


ivtH'ieinla  o 


f.  i:»7 


iiillainiiialioii  of,  lit" 


ii'ilcnia  o 


f,  l;!7 


svpliilisof.  110 


tUlM 


Tculosis  of,   1 10 


Tonus  of  iniisi'lc,  \s\ 
Toplii  in  ijout,  (iOl 
Toplius,  .■)20 

■roti|Mitcntial  cell.   I.'i,  20S 
'I'oxciiiia.  I  1-) 
I'oxic  .allxiininuria.  (lO^I 

(rdcina,  1170 
Toxins.  S.'i,  l.'iti 


ai'tion  < 


if,  s:, 


ititoxins  ami,  l")(> 
of  Macillus  diplitlicria',  N.'> 


of  I 


lactcria, 


M.  S.-1 


liialodes  of.  I2."i 


Ictiriition  of.  l.'iti 
devclopinent  of.  in  protozoa,  'Xi 
excretion  of,  l>y  nieta/.oa,  O'.l 
resenililancc  of.  to  enzymes,  ,S.'i 
tetanus.  l.">7 


T 


IXoplK 


d.  I.- 
Ik 


!.■ 


1.' 


Trachea,  420,  140 
'I'rachonia,  .")!  1 


raction  aneurysm, 


l(;s 


livertiellhi  of  (isophauus. 


ao 


Transitional  lepide 

neoplasms,  220 
Transplantation,  lOO 

autoplastic,  100 

of  hone,  201 

heteroplast       100 


r4 


isoplast 


201 


f  mammary  ulaii'l.  2(M) 


i(f  mucous  tiK'Hi 


t.raiies,  201 


l.f. 


2(HI 


f  pericliondriuni.  201 


periosteum, 
serous  tiieiii 


201 
hiaiii 


201 


of  teeth,  201 

of  thyroid,  2(K1 

of  vfssels,  202 
Traum.atic  causes  of  inflammation.  122 

liironibosis  of  dura  mater.  .'lOl 
Tremor,  4M4 

Treiionema  i)alliiluiii.  ^M.  OK 
Trichina  spiralis,  cysts  of,  20.") 
Trichina'.  00 

Trichiniasis  of  muscles.  (174 
Trichocephalas  di'struction 

00 
Trichotnonas,  00 
Trimcthvl.inr  1,  110 


of  tissue  bv. 


Triplets,  (14 

Tropical  ab.si  esS  of  livrr.  .")7.") 

Truncus  arteriosus,  persistent.  :!S(1 


750 


rxnEx 


TryiHinosoiim  briicci,  d") 

cviiii.ii,  '.>'t 

Kaiiihiciis(>,  ((."> 
'rry|)iiii(is()ni('s,  (t4,  it") 
Tn  lisiii()(jcii,  jictivation    of.  In-    cntcro- 

kiiiusc,  174 
T.st'-I.so  Hy  disease,  !).") 
Tubal  al)<)rti(ni,  (Miti 

Keslation,  tJ.W 
Tube,  Fall()i>ian.  <)">;{ 
TulxTcle,  l.SK 

of  iris,  .^12 
TulxTculoirias  of  liver,  .")S2 
Tut)ereiil<>sis  of  adrenals.  122 

ai'ronenic,  4(')() 

of  bile  duet,  :>S2 

of  bladder.  t)2() 

of  bone,  (),S.{ 

of  brain,  4,S!> 

of  bursa-,  iuS  , 

of  eonjunetiva,  .'d  I 

of  <'ornea,  .")12 

of  dura  mater.  .")(K{ 

of  ear.  r.IS.  .■)2() 

of  Fallopian  tubes.  ()."4 

heniat overlie,  4(14 

of  intestines,  .Vil? - .").") 

of  joints.  W.i 

of  kidneys.  (ilK 

of  liver,  .").S1 

of  lunifs,  4.ji) 

of  lymph  nodes,  412 

lymplio)renie.  4t')4 

of  tnammary  Kl.and.  <>li7 

miliary,  4(>4 

of  mouth.  i')2.") 

of  luu.setes.  t'>74 

of  myocardium,  .'iss  ! 

of  no.se.  4;!t)  , 

of  (r.sopha^us.  ,");{1 

of  ovary,  tio")  j 

of  pai'ereas,  iiii't 

of  penis,  (i;j2  I 

of  peripheral  nerves,  MS 

of  periloneuiri,  ">().')  I 

of  pia-araehiioiil,  ."lO'i 

of  p'aeenta,  t)ti4  i 

of  jjieura",  470 

of  prostate,  iVSA 

of  salivary  tjlands,  ")2S  | 

of  skin,  701  | 

of  spermatic  cord.  (IJO  j 

of  spinal  cord.  4!Mi.  .'itM) 

of  spleen,  41.S 

of  stomach,  't'M> 

of  tendon  sheaths,  (177 

of  testes,  ();{S 

of  thvnnis,  472  I 

of  toii.sils,  44(1  r 

nf  tunica  vatriiialis  testis.  t(;i7 

of  uri'lers.  (124 

of  urethra.  ()2!l 

of  uterus,  tl4!t 

of  vulva,  (141  ' 


Tuberculou>    bronclio])neimioni;i,    4'>9, 
4til 
colitis,  .')tlO 
'  laryngitis,  442 

pneumonia,  4(11 
pyelonephrosis,  (124 
pyonephrosis,  (11!) 
Tubo-ovarian  abscess,  tl.^.') 
Tumefaction  in  typhoid  fever.  .")0 
Tumors,  20(1.     Sic  also  Neoplasms, 
nomenclature  of,  22(1 
ordinary.    Sic  Ulastomas. 
in  tumore,  20!(,  (KM) 
Timica  vaginalis  testis,  (iUti 

abnormalities  of.  (1;{(1 
inflammation  of,  V\',U'> 
hydrocele  of,  tll{(l 
i  syphilis  of,  (137 

i  tuhei 


Twins,  (12 

dichorial,  (12 
heteriMiphal,  (12 
monochorial,  (I'J 
moTioophal,  (12 
une<iual.  (12 

Typhlitis.  MS 

"'rvt 


erculosis  of,  037 
tumors  of.  (i;{7 


147 


llo 


Fyphoid  carri<'rs, ' 
fever,  riW  .")");} 

ctat  criblee  in,  o")0 
hemorrhafte  in,  .")">3 
intestines  in,  .")4il 
necro.sis  in,  .").">() 
perforation  in,  'tri'.i 
predisposition  towan 
relap.ses  in,  .")").'{ 
skin  in,  (l!t7 
stomach  in,  ii'M 
tumefaction  in,  "),")() 
ulcer  in,  .j.')2 


i.rKR,  7(K) 

Htherom.'itous.  402 

of  cornea,  oil,  .512 

healiii)!,  7(M) 

indolent,  700 

of  intestine,  ,")4.S 

I)h.a(!;e<lenie,  700 

rodent.  2G4 

serpitjinous,  .512 

of  skin,  7(Kt 

spreading,  7(K) 

of  stomach,  .5;i(> 

in  typhoid  fever,  .5.52 
leeration  of  peritoneum,  .504 
Icerative  colitis,  .5.5S 

("tidocarditis.  .3i((l 

itiHammalion.  i:{4 

stomatitis,  .524 

tuberc\ilosis,  4(12 
'tramicroscopic  tnicrocrganisms,  93 


IXDEX 


757 


Cltniviolot 

7.S 
I'tiihilic: 


rays    as    cause    of    disease, 


il  lord,  ()0."> 
aiigiomit  of,  ()('),'> 
cysts  of,  (i(i,5 
defeneration  of,  tltio 
liernirt  of,  7'2,  IMio 
looped,  tit)") 
myxoma  of,  (H'tit 
septic  infection  of.  (Mm 
syphilis  of,  titii') 
twisted,  tMJo 
hernia,  .jtiit 
I'nconscioiisness,  4K0 
"I'nditTerentiation,"  2im 
rnequal  twins,  t)2 
I'nicentric  blastotna,  217 
ITnilateral  kidney,  tHW 
Universal  |)eritonitis,  hKi 
"rnresolved"  pneumonia,  4.")7 
I'rachal  cysts,  2.S<»,  2i«»,  (>2r) 
Cratic  calculi,  ;{l(i 

inspissation  in  infancy,  :{17 
I'rea  in  iirine,  ()t)2 
rreniia,  t)()7 

causes  of,  lOo 
Ureteral  colic,  023 
Ureteritis,  ((23 
Ureters,  622 

abnormalities  of,  t>22 

calculi  in,  023 

carcinoiiia  of,  024 

eysticercus  of,  ()24 

cysts  of,  024 

echinococcus  of,  024 

eustrongylus  (jitJus  of.  024 

filaria  sanguinis  of,  024 

foreign  bodies  in,  023 

({ravel  in,  023 

kinks  in,  023 

inflammation  of,  023 

obstruction  of,  023 

papilloma  of,  024 

parasites  of,  024 

sarcoma  of,  024 

stenosis  of,  023 

teratoma  of,  024 

tuberculosis  of,  024 

t  lunors  of,  t)24 
Urethra,  02,S 

absence  of,  02S 

anomalies  of,  ti2S 

carcinoma  of,  ti2!) 

caruncles  of,  02!) 

condylomas  of,  02!l 

fibroma  of,  02!) 

foreign  bodies  in,  02!) 

inflammation  of,  02S 

sarcoma  of,  02!) 

stricture  of,  t)2!) 

syi)liilis  of,  02!) 

tut)ercul()sis  of,  02!) 

tumors  of.  021) 
Urethritis,  028 


Urethritis,  Konorrh<eal,  02.S 
I'rie  acid,  27,  107 

calculi.  310 
infarct,  317 
in  kidney,  020 
in  urine,  002 
Urinary  calculi,  310 
function,  ,")!)!) 
gravel,  317 
Urination,  disturbances  of,  004 
Urine,  albumin  in,  (M)2 
albumoses  in,  (HJ3 
creatinin  in,  (502 
excretion  of,  decrea.sed,  (M)2 

increaseil,  001 
incontinence  of,  tM)") 
retention  of,  (it),") 
solids  in,  002 
urea  in,  002 
uric  acid  in,  002 
Urobilin,  pigmentation  due  to,  324 
Urobilinuria,  322 
Urnchrome,  .322 

Urogenital  duct,  tumors  of,  27 "> 
Urtii'a,  hvbrids  of,  showing  Mendel's  law, 

4!) 
Urticaria,  007 
Uterine  fibroid,  241 
Uterocele,  (i44 
Uterorectal  fistula,  ()44 
Uterovesical  fistula,  044 
Uterus,  t>43 

abnormalities  of,  043 
absence  of,  043 
adenocarcinoma  of,  t»,")l 
adenoma  of,  051 
adenomyoma  of,  243,  0.")0 
anomalies  of,  044 
anteflexion  of,  (544,  04o 
atrophy  of,  040 
bicornis,  ()44 
bicornuate,  (544 
bruising  of,  04() 
carcinoma  of,  051 
cysts  of,  049,  (552 
didelphys,  043 
dilatation  of,  040 
dysplasias  of.  044 
dystrophies  of,  044 
elevation  of,  (')45 
(mdothelioma  of,  ()52 
epithelioma  of,  051 
fibroid  of,  241,  050 
fibromyoma  of,  0.50 
fission  of  o,s  of,  044 
flexion  of,  045 
f<i'talis,  t)44 
foreign  bodies  in,  049 
hemorrhage  of,  040,  047 
hyperemia  of,  04(i 
hyi)ertrophy  of,  O.jO 
hypoplasia  of,  043 
infantile,  044 
inflanunation  of,  047 


J 


.■)S 


IXDEX 


Utfrus,  inversion  of.  M'> 
liKttiiifnts  of,  ()<ll 

absence  of,  litil 

.•idcnoinii  of.  ()()2 

:moiriali('s  of,  (Mil 

cysts  of,  •)<>!,  (»t)2 

fibroiiia  of,  (it)2 

licniorrliaKc  in.  ''><">1 

liypcrlrophy  of,  <)<>2 

iiiHainniation  of,  ti()I 

lipoma  of,  &V2 

inyoina  of,  (><)2 

plili-holith  in,  (i(il 

sarcoma  of,  t)(>2 

Icratoiiia  of,  t)()2 

tumors  of,  <)02 
lipoma  of,  («() 
myoma  of,  241-2415,  lioO 
myxomyoma  of,  tl.'id 
parasites  of,  ()4!l 
pcrfonilion  of.  ti4('> 
|in«'i(lcntia  of,  (i4."> 
prolapse  of.  t>4."i 
puerperal,  (Mi2 

ehoriiwpithelioma  of,  tl'i;? 

(ieciiluoma  malijinuin  of.  <>)>:{ 

syncytial  carcinoma  of,  (\iV-i 

tumors  of.  (Ml:} 
retroflexion  of.  (>44.  t)4.") 
retroverled.  (144 
ruiilure  of,  ()4(> 
sarcoma  of,  t'>ri2 
septus,  044 
stenosis  of,  (>44,  tt4.5 
sy|)liilis  of,  (i4!l 
tuoerculosis  of.  ('>4!t 
tumors  of.  <>.")() 
unicornis,  "14 
I'vulitis,  4:57    . 


VAcnxiA,  organism  of,  !W 
\acuolar  (Icfseneration,  •W>,  (i2l> 
Vacuoles,  IS 
\agat)on(l's  disea.se.  702 
Vagina,  042 

abnormalities  of,  042 

absence  of.  ()42 

atresia  of,  042 

carcinoma  of,  squamous-celled,  04:{ 

chorio-epithelioma  of,  (')4;5 

(lui>lication  of,  042 

hemorrhage  of,  f>42 

inflammation  of.  ti42 

h'iomyoma  of,  04:i 

l)ji.ssive  congestion  of,  042 

sarcoma  of,  M'.i 

tiunors  of,  04;j 
Vaginal  hernia,  509 
Vaginitis,  042 
Valves,  auriculoventrioular,  373 

semilunar,  376 


Valvular  piieumot)  ivux,  4(>7 

Valvulitis.  :iit3 

\;iriation,  here<lity  and.  47 

spontaneous.  .">() 
N'arices  of  intestines.  .")97 
of  lymph  nodes.  412 
\'ari('ocele  of  spermatic  cord.  041) 
X'aricose  aneurysm,  4I).S 
bronchiectasis.  440 
veins,  27S,  410 
Variola,  O'.Mt 
Xa'rix,  aneurysm.-d.  4()S 
\'as  deferens.  1)40 

inflanniiation  of,  f)4() 
Vas<'ular  area,  inflammation  in,  123 
Vascularization  of  new  formed  connectivi 

tis.sue,  130 
Vegetable  forms,  pathogenic,  other  thai 

bacteria,  !)2 
\'egelations,  13."),  3'.)4 
cardiac,  34!».  3.')I 
fibrinous,  i:,'") 
Vegetative  cell.  44 

ai'tivity.  3S 
endocarditis,  3!tt) 
Veins,  411) 

calcification  of,  410 
dihitation  of,  410 
hbrosisof,  410 
Inflammations  of,  410 
thrombosis  of,  410 
varicose,  411) 
Venereal  wart,  2.").S,  0.">2 
Venoms,  animal,  lOS 
Venous  hyp<"remia,  .33.S 
pul.se.  372 
t  lirombus,  3.")() 
Ventri<'le,  fourth,  hydrocele  of,  292 
hydrocephalus  of,  4S0 
of  heart,  373 

dilatation  of,  pathological,  37") 
distention  of,  374 
Vernal  conjunctivitis,  .")I1 
\'erruca',  704 

N'errucose  endocarditis,  3!14,  3!>.") 
Version  of  uterus,  (')44 
Vesieo-umbilical  fistula,  02") 
\'esicovaginal  fissure,  73,  (i43 
Vesicuhe  seminales,  040 
\'essels,  poisons  acting  on,  S2 

transplantation  of,  202 
Vicariovis  cell  activity,  37 
hypertrophy,  ISM 
nienstruation    in    mammary 
000 
Vincent's  angina,  439 
Vinilent  bubo,  032 
Virus,  filterable,  92 
Vitellins,  2.') 

\itello-inteslinal  cyst.s,  289,  507 
Vitiligo,  ;03 

i  Vitreous   degeneration   of   myocartliur 
I  390 

'         humor,  516 


glan( 


INDEX                                                  759 

Volvulus  of  intestines,  ")4.") 

Weaver's  lM>tlom,  07S 

\on  HeektiuKliuusen's  disease,  2.H),  1 

M7 

Wens,  2!M),  707 

Vulva,  WO 

White  infarct  of  liver,  ."544,  072 

abtiormalilies  of,  640 

kidney,  large,  012 

iiriKioiiiu  of,  04 1 

I)neunionia,  4().") 

atrophy  of,  (141 

soft  en.  ig  of  brain,  4H7 

)40 

eareiiioiiia  of,  s(iuainoiis-<'eileii, 

042 

swelling  of  knee,  0S4,  0!):{ 

ehondroina  of,  1)42 

Widal   reaction,   102. 

PUtaiuKuis  (listurbanees  of,  (141 

WolHiun  body,  cysts  of,  2S<» 

eysts  of,  f)42 
elephantiasis  of,  041 

Worms  in  peritoneum,  566 

Wrist-*lrop,  508 

fibroma  of,  ti4 1 

lienuitonia  of,  ()41 

lieniorrliaRC  of,  641 

X 

n     1  *>X 

infective  granulomas  of,  t>41 

11,   1  >.f  1 

<*oniuH'tiv*' 

inflammation  of,  (141 
lipoma  of,  M2 

Xantiiin,  27,  107 
calcuH,  :iis 

other  tliiiii 

lupus  of,  I>41 

Xanthelasma,  70.'{ 

\'iii\  1    iiit^ii 

myoma  of,  ()42 

Xanthoma,  2;{;{,  705 

luevi  of,  ()41 

X-rays  as  cause  of  disease,  7S 

(edema  of,  ()41 

cells  of  tumors  and,  2S7 

passive  eongeslion  of,  <i41 

sarcoma  of,  melanotic,  (142 

sy  )hilis  of,  041 
tuberculosis  of,  041 

T 

tumors  of,  (>4I 

Yaws,  (tS 

X'ulvitis,  acute,  041 

Yeasts,  <»2 

N'ulvovaginitis,  042 

Yellow  atrophy  of  liver,  acute,  .574 
fever,  organism  of,  92,  !•:{ 

prc<lisposition  toward,  115 

W 

VVALLKttiAN  degeneration,  IDS 

z 

Warts,  2.-)7,  7():{.  704 

venereal,  2.").S 

Zknkku's  degeneration  of  muscles,  328, 

VVassermann  reaction  in  svphilis,  10 

7,  lOS 

070 

Water  of  cell,  :U 

of  niyocardiiun,  .'iOO 

f,  2!)2 

ionization  and,  ;{2 

Zona  fa.sciculata,  421 

<i) 

Waxv  cast,  :{12 

glomerulosa,  421 

deceneration,  .TiS,  070 

reticularis,  V?l 

opiral,  37^ 

spleen,  ;{(),S 

•  Zymophore,  IT,, 

